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Vocal Signs and Symptoms Related to COVID-19 and Risk Factors for their Persistence

  • Ana Paula Dassie-Leite
    Correspondence
    Address correspondence and reprint requests to Ana Paula Dassie-Leite, Universidade Estadual do Centro-Oeste - UNICENTRO, PR 156, Km 07; Irati, Paraná 84500-000, Brazil.
    Affiliations
    Professor at the Speech-Language Pathology Department, Universidade Estadual do Centro-Oeste - UNICENTRO. PR 156, Km 07; Irati, Paraná, Brazil

    Professor at the Interdisciplinary Postgraduate Program in Community Development, Universidade Estadual do Centro-Oeste - UNICENTRO. PR 156, Km 07; Irati, Paraná, Brazil
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  • Tatiane Prestes Gueths
    Affiliations
    Speech Language Pahologist. Saldanha Marinho st, 2820. Bairro dos Estados; Guarapuava, Paraná, Brazil
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  • Vanessa Veis Ribeiro
    Affiliations
    Professor at the Speech-Language Pathology Department, Universidade Federal de Sergipe - UFS. Governador Marcelo Dedá Avenue, 13, Centro, Lagarto, Sergipe, Brazil

    Professor at the Associate Postgraduate Program in Speech-Language Pathology, Universidade Federal da Paraíba - UFPB. Cidade Universitária, Conjunto Presidente Castelo Branco III, João Pessoa, Paraíba, Brazil
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  • Eliane Cristina Pereira
    Affiliations
    Professor at the Speech-Language Pathology Department, Universidade Estadual do Centro-Oeste - UNICENTRO. PR 156, Km 07; Irati, Paraná, Brazil
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  • Perla do Nascimento Martins
    Affiliations
    Professor at the Speech-Language Pathology Department, Universidade Estadual do Centro-Oeste - UNICENTRO. PR 156, Km 07; Irati, Paraná, Brazil
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  • Christiane Riedi Daniel
    Affiliations
    Professor at the Physioterapy Department, Universidade Estadual do Centro-Oeste - UNICENTRO. Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167 - Bairro - Vila Carli, Guarapuava, Brazil
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      Abstract

      Objective

      To compare the occurrence of vocal signs and symptoms before, during, and after coronavirus disease (COVID-19) and analyze possible risk factors for the persistence of these signs and symptoms after disease resolution.

      Methods

      This was an observational, analytical, and cross-sectional study. The participants were 45 individuals of both sexes, with a mean age of 44 years, who were previously affected by COVID-19. All participants answered a questionnaire about sociodemographic data, smoking history, disease course, vocal complaints, and the vocal signs and symptoms list (SSL), referring to three timepoints (before, during, and after COVID-19).

      Results

      The most commonly reported vocal signs and symptoms before COVID-19 were phlegm (26.67%; n=12) and dry throat (24.44%; n=11). During COVID-19, the most frequent vocal signs and symptoms were tired voice after short-term use (73.33%; n=33) and dry throat (71.11%; n=32). After the disease, the most reported vocal signs and symptoms were dry throat (57.78%; n=26) and phlegm (53.33; n=24). The self-perception of vocal signs and symptoms before COVID-19 was lower than that during and after COVID-19 (P < 0.001). Vocal complaints after COVID-19 and oxygen therapy were predictors of self-perception of vocal signs and symptoms after COVID-19.

      Conclusions

      Individuals affected by COVID-19 had a higher frequency of vocal signs and symptoms during the disease. However, after remission, the frequency of vocal signs and symptoms was higher than that at baseline. The need for oxygen therapy may indicate a risk for a higher occurrence of vocal signs and symptoms after COVID-19.

      Key Words

      INTRODUCTION

      COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus has a clinical spectrum ranging from asymptomatic infections to deaths.

      Brasil. Ministério da Saúde. Portaria MS/GM n. 188, de 3 de Fevereiro de 2020. Declara Emergência Em Saúde Pública de Importância Nacional (ESPIN) Em Decorrência Da Infecção Humana Pelo Novo Coronavírus (2019-NCoV). Brazil: Diário Oficial da União, Brasília (DF); 2020. http://www.in.gov.br/web/dou/-/%0Aportaria-n-188-de-3-de-fevereiro-de-2020-241408388%0A.

      Approximately 80% of COVID-19 patients may be asymptomatic or oligosymptomatic (few symptoms). Of the 20% who require hospital care because they have difficulty breathing, approximately 5% may require oxygen therapy due to hypoxemia.

      Brasil. Ministério da Saúde. Portaria MS/GM n. 188, de 3 de Fevereiro de 2020. Declara Emergência Em Saúde Pública de Importância Nacional (ESPIN) Em Decorrência Da Infecção Humana Pelo Novo Coronavírus (2019-NCoV). Brazil: Diário Oficial da União, Brasília (DF); 2020. http://www.in.gov.br/web/dou/-/%0Aportaria-n-188-de-3-de-fevereiro-de-2020-241408388%0A.

      Acute symptoms of COVID-19 include cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, anosmia, and dysgeusia.
      • Docherty AB
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      Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study.
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      COVID-19 can lead to respiratory complications, which in turn may result in cardiac (arrhythmias and myocardial), renal (acute kidney injury), gastrointestinal, neurological (neuropathy, encephalopathy), endocrine, and musculoskeletal consequences (weakness, pain, and fatigue).
      • Zhang Y
      • Ma ZF.
      Impact of the COVID-19 pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study.
      ,
      • Boldrini M
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      Despite numerous studies on the acute form of COVID-19, to date, there is no established deadline to describe the slow and persistent condition in individuals with long-term sequelae of COVID-19.

      Lopez-Leon S, Wegman-Ostrosky T, Perelman C, et al. More than 50 Long-term effects of COVID-19: a systematic review and meta-analysis. medRxiv. doi: 10.1101/2021.01.27.21250617

      Abnormal signs and symptoms or parameters that persist for more than 2 weeks after the onset of COVID-19 and do not resolve (baseline values) may have potential long-term effects.
      • Tenforde MW
      • Kim SS
      • Lindsell CJ
      • et al.
      Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network — United States, March–June 2020.
      These symptoms occur mainly in survivors of severe and critical COVID-19, and long-lasting effects also occur in individuals with mild infection and those who require no hospitalization.
      • Townsend L
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      • O'Brien K
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      Persistent poor health Post-COVID-19 is not associated with respiratory complications or initial disease severity.
      Patients who had COVID-19 and required medical hospitalization often have symptoms after approximately 2 months,
      • Carfì A
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      • Landi F.
      Persistent symptoms in patients after acute COVID-19.
      ,
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      especially those who needed intensive care unit (ICU) care.
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      The main symptoms are fatigue,
      • Carfì A
      • Bernabei R
      • Landi F.
      Persistent symptoms in patients after acute COVID-19.
      ,
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      dyspnea,
      • Carfì A
      • Bernabei R
      • Landi F.
      Persistent symptoms in patients after acute COVID-19.
      ,
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      joint pain,
      • Carfì A
      • Bernabei R
      • Landi F.
      Persistent symptoms in patients after acute COVID-19.
      chest pain,
      • Carfì A
      • Bernabei R
      • Landi F.
      Persistent symptoms in patients after acute COVID-19.
      and psychological distress.
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      Voice-related symptoms, more specifically related to laryngeal sensitivity and vocal changes, have also been described.
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      Regarding vocal symptoms, a single study specifically on this topic analyzed the prevalence of dysphonia in 702 European patients with mild to moderate COVID-19. The data showed that 27% of the patients had dysphonia. Dysphonic patients had a higher occurrence of cough, chest pain, sticky sputum, arthralgia, diarrhea, headache, fatigue, nausea, and vomiting. The severity of dyspnea, dysphagia, ear pain, facial pain, sore throat, and nasal obstruction was higher in the dysphonic group than in the non-dysphonic group.
      • Lechien JR
      • Circiu MP
      • Crevier-Buchman L
      • et al.
      Post-COVID-19 paradoxical vocal fold movement disorder.
      It is believed that the vocal symptoms present after COVID-19 may not only be related to orotracheal intubation
      • Bertone F
      • Robiolio E
      • Gervasio CF.
      Vocal cord ulcer following endotracheal intubation for mechanical ventilation in COVID-19 pneumonia: a case report from Northern Italy.
      but also to respiratory sequelae. In clinical practice, vocal complaints associated with respiratory complaints have been observed. This is because the integrity of the respiratory system is fundamental for proper voice production with respect to providing the air pressure necessary for phonation.
      • Behlau M.
      Voz: O Livro Do Especialista.
      • Coelho CS
      • Alves ELO
      • Ribeiro VV
      • et al.
      Tempos máximos fonatórios e sua relação com sexo, idade e hábitos de vida em idosos saudáveis.
      • Ribeiro V
      • Ribeiro VV
      • Dassie-Leite AP
      • et al.
      Handicap, vocal complaints and maximum phonation time in women smokers.
      • Coelho AR
      • Siqueira LTD
      • Fadel CBX
      • et al.
      Influence of the speech-language pathologist's orientation on maximum phonation times.
      Moreover, in the new scenario imposed by COVID-19, some laryngeal occurrences have been described, with scarcely known causes, as paradoxical movement of the vocal fold.
      • Lechien JR
      • Circiu MP
      • Crevier-Buchman L
      • et al.
      Post-COVID-19 paradoxical vocal fold movement disorder.
      It is necessary to understand more deeply the occurrence of vocal signs and symptoms before, during, and after COVID-19. Thus, it is possible to contribute to the management of symptoms and maximize the functional recovery of patients.
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      Therefore, this study aimed to compare the occurrence of vocal signs and symptoms before, during, and after coronavirus disease (COVID-19) and analyze possible risk factors for the persistence of these symptoms after disease resolution.

      MATERIAL AND METHODS

      This study has an observational, analytical, cross-sectional, and hybrid design. The study was approved by the Ethics Committee on Research with Human Beings of the institution of origin, under number 4.319.245.
      Individuals referred by the health department of a Brazilian municipality to the evaluation and rehabilitation service after COVID-19 developed by the home institution participated in the study. The service is composed of speech therapists and physiotherapists.
      The inclusion criteria were as follows: both sexes, age ≥18 years, a diagnosis of COVID-19 confirmed by reverse transcription polymerase chain reaction (RT-PCR), and referral from the public health service of the city where the institution proposing this research is located. Exclusion criteria were: asymptomatic persons; invasive mechanical ventilation; history of respiratory disorders or other health changes that impacted voice and communication before COVID. The eligibility criteria were applied using direct questions.
      All participants answered a questionnaire about sociodemographic data (sex, age, weight, and height), smoking history, course of the disease (date of diagnosis, need for hospitalization, type and duration of hospitalization, noninvasive mechanical ventilation, oxygen therapy), and vocal complaints (before, during, and after COVID-19).
      Following this, the individuals answered the vocal signs and symptoms list (SSL), which investigates the presence or absence of 14 vocal signs or symptoms.
      • Roy N
      • Merrill RM
      • Thibeault S
      • et al.
      Voice disorders in teachers and the general population.
      A brazilian portuguese translation of the instrument was used.
      • Behlau M
      • Zambon F
      • Guerrieri AC
      • et al.
      Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects.
      Each symptom was addressed with respect to three distinct timepoints: before, during, and after COVID-19. According to the authors' instructions, the total score of the questionnaire was calculated using a simple sum. Moreover, a descriptive analysis of individual symptoms was conducted.
      The vocal symptoms were self-reported based on the following questions: Vocal signs and symptoms before COVID-19 - participant should answer considering whether the sign/symptom was recurrent or persistent in his/her day-to-day before the diagnosis of the disease; Vocal signs and symptoms during COVID-19 - participant should respond considering if the sign/symptom questioned occurred during the active period of the disease, which comprised the interval between the 3rd and 11th day; Vocal signs and symptoms after a COVID-19 - participant should respond considering whether the sign/symptom was recurrent or persistent from the day of remission of the disease to the current day (day of data collection).
      Data were tabulated and statistically analyzed using SPSS 25.0. The inferential analysis was performed using the Friedman test to compare the results obtained with the SSL before, during, and after COVID-19. Multiple pairwise comparisons with Bonferroni corrections were performed for cases of significance. Multiple linear regression with the selection of variables by the stepwise method was performed to analyze the factors related to the maintenance of symptoms after COVID-19. For all inferential analyses, a significance level of 5% was adopted.

      RESULTS

      Forty-five individuals participated in this study, with a mean age of 44 years and 10 months, 24 females and 21 males. The descriptions of the other variables independent of sociodemographic data, disease course, and vocal complaints are shown in Tables 1 and 2.
      TABLE 1Descriptive Analysis of Independent Quantitative Variables
      VariableMeanSDMinimumMaximum1QMedian3Q
      Age44.8913.1519.0078.0035.5045.0055.50
      Body mass index29.765.2620.2842.2725.9030.6133.53
      Time since COVID-19 diagnosis (in days)41.9117.1919.00107.0030.0038.0047.50
      Days of hospitalization1.292.770.0013.000.000.000.50
      Days of ICU stay0.511.840.0010.000.000.000.00
      Descriptive analysis.
      SD, standard deviation; 1Q, first quartile; 3Q, third quartile.
      TABLE 2Descriptive Analysis of Independent Binary Nominal Binary Variables
      VariableNoYes
      n%n%
      Hospitalization3168.891431.11
      Noninvasive ventilation4497.7812.22
      Oxygen therapy3680.00920.00
      Smoking history3577.781022.22
      Vocal complaints before COVID-194088.89511.11
      Vocal complaints during COVID-192146.672453.33
      Vocal complaints after COVID-193168.891431.11
      Descriptive analysis.
      n, absolute frequency; %, relative frequency.
      Table 3 shows descriptive analysis regarding the presence or absence of the 14 vocal signs and symptoms investigated in the SSL. The vocal signs and symptoms most commonly reported before COVID-19 were phlegm (26.67%; n=12) and dry throat (24.44%; n=11). During COVID-19, the most frequent vocal signs and symptoms were tired or changed voice after use for a short time (73.33%; n=33) and dry throat (71.11%; n=32). After COVID-19, the most reported vocal signs and symptoms were dry throat (57.78%; n=26) and phlegm (53.33; n=24).
      TABLE 3Descriptive Analysis of Binary Nominal Qualitative Variables Related to SSL, in the Pre, During, and After COVID-19 Timepoints
      SymptomsBeforeDuringAfter
      n%n%n%
      Hoarseness
      No3986.672351.113373.33
      Yes613.332248.891226.67
      Voice becoming tired or change after use for a short time
      No4395.561226.673066.67
      Yes24.443373.331533.33
      Trouble singing or speaking low
      No4497.783475.563884.44
      Yes12.221124.44715.56
      Difficulty in projecting your voice
      No4293.332555.563680.00
      Yes36.672044.44920.00
      Difficulty singing high
      No45100.003475.563986.67
      Yes00.001124.44613.33
      Discomfort when speaking
      No45100.002657.784088.89
      Yes00.001942.22511.11
      Monotone voice
      No4395.563168.894191.11
      Yes24.441431.1148.89
      Effort to speak
      No45100.002351.113986.67
      Yes00.002248.89613.33
      Dry throat
      No3475.561328.891942.22
      Yes1124.443271.112657.78
      Sore throat
      No4088.892555.563884.44
      Yes511.112044.44715.56
      Phlegm
      No3373.331635.562146.67
      Yes1226.672964.442453.33
      Acidic or bitter taste in the mouth
      No4088.891840.002862.22
      Yes511.112760.001737.78
      Difficulty swallowing
      No4497.783577.784395.56
      Yes12.221022.2224.44
      Voice instability or tremor
      No45100.003577.783986.67
      Yes00.001022.22613.33
      Descriptive analysis.
      n, absolute frequency; %, relative frequency.
      Table 4 indicates a significant difference in self-perception of vocal signs and symptoms before, during, and after COVID-19 (P < 0.001). The self-perception of vocal signs and symptoms before COVID-19 was lower than during (P < 0.001) and post-disease (P < 0.001). Moreover, the self-perception of vocal signs and symptoms after COVID-19 was lower than during the disease (P < 0.001).
      TABLE 4Comparison of Self-Perception of Vocal Signs and Symptoms Before, During and After Having COVID-19
      VariablesMeanSDMinimumMaximum1QMedian3QX2P-valuePairwise
      Vocal signs and symptoms

      before COVID-19
      1.091.3906.000.001.001.0066.53<0.001Before < During (P < 0.001)

      = After (P < 0.001);

      After < During (P < 0.001)
      Vocal signs and symptoms

      during COVID-19
      6.223.63014.003.007.008.50
      Vocal signs and symptoms

      after a COVID-19
      3.243.00012.001.003.004.00
      Friedman test; multiple comparations by pairwise with Bonferroni correction.
      SD, standard deviation; 1Q, first quartile; 3Q, third quartile.
      Regression to verify whether the variables (age, body mass index, time since COVID diagnosis, days of hospitalization, days of intensive care unit (ICU) stay, hospitalization, noninvasive ventilation, oxygen therapy, smoking history, vocal complaints before, during, and after COVID-19), were related to self-perception of vocal signs and symptoms after COVID-19 resulted in a statistically significant model (F(2,43) = 18.076; P < 0.001; R2 = 0.422). Vocal complaint after COVID-19 (β = 0.549; t = 4.508; P < 0.001) and oxygen therapy (β = 0.333; t = 2.737; P = 0.009) were predictors of self-perception of vocal signs and symptoms after having COVID-19 (Table 5).
      TABLE 5Multiple Linear Regression Model of Independent Variables as Predictors of Self-Perception of Vocal Signs and Symptoms After Having COVID-19
      ModelBβtP-valueVIF
      (Constant)1.6223.3230.002
      Vocal complaints after COVID-193.6490.5494.508<0.0011.001
      Oxygen therapy2.4950.3332.7370.0091.001
      Multiple linear regression, stepwise method.
      r² = 0.422.
      VIF, Variance inflation factor.

      DISCUSSION

      Understanding the impact of COVID-19 on voice and communication is extremely important for speech therapists to develop appropriate and resolutive actions for the population.
      The types of signs and symptoms most reported during and after COVID-19 are related to pulmonary and laryngeal aspects. The most common symptom reported during the pandemic was tired or changed voice after use for a short time (73.33%; n=33). This symptom persisted in 33.3% of individuals after COVID-19, and only 4.4% of patients reported it before COVID-19. This symptom is directly associated with respiratory sequelae related to the disease, and its persistence refers to the maintenance of fatigue symptoms, pointed out in the literature as the most frequent symptom type after COVID-19.
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      In general, symptoms related to vocal tract sensations have been observed in other studies investigating patients with COVID-19 at varying frequencies.
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      Cough is one of the most common symptoms of the disease and may be present in approximately 76% of cases,
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      causing irritation, edema, and even phonotrauma in the vocal folds. Regarding the period after COVID-19, there is a possibility that 25% of individuals will continue experiencing laryngeal sensitivity.
      • Halpin SJ
      • McIvor C
      • Whyatt G
      • et al.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      This study hypothesized that respiratory sequelae and vocal tract symptoms related to COVID-19 might be risk factors for the development of dysphonia. This study indicates that hoarseness was present in 48.89% of the cases during the disease, higher rates than those described in the literature regarding dysphonia, which is 27%.
      • Lechien JR
      • Circiu MP
      • Crevier-Buchman L
      • et al.
      Post-COVID-19 paradoxical vocal fold movement disorder.
      In this study, 26.67% of patients presented with symptoms of hoarseness after the disease. No specific studies on this symptom were found, but the results are compatible with those of a study that showed that approximately 25% of patients reported persistent vocal changes after the disease.
      • Halpin SJ
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      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      Some atypical cases of dysphonia during or after COVID-19 have been reported, including vocal fold immobility, paradoxical movement of vocal folds, and psychogenic dysphonia.
      • Lechien JR
      • Circiu MP
      • Crevier-Buchman L
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      Post-COVID-19 paradoxical vocal fold movement disorder.
      ,
      • Buselli R
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      • Necciari G
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      Sudden and persistent dysphonia within the framework of COVID-19: the case report of a nurse.
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      For this reason, in addition to the possibility of vocal disorders due to respiratory sequelae or vocal tract symptoms commonly related to the disease, each case must be analyzed individually according to clinical history and vocal manifestations.
      The highest frequency of vocal signs and symptoms was observed during COVID-19, with differences compared to those before and during the disease. The frequency of vocal signs and symptoms after COVID-19, although lower than during COVID-19, was higher than that before COVID-19. Thus, it was confirmed that many signs and symptoms persisted even after curing the disease. A median of one symptom was noted before COVID-19, which is compatible with that in the general population.
      • Roy N
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      Voice disorders in teachers and the general population.
      The median of seven vocal signs and symptoms during COVID-19 was compatible with the numbers presented for individuals with dysphonia in general.
      • Roy N
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      Voice disorders in teachers and the general population.
      After COVID-19, the median of three symptoms, although lower than that commonly presented by individuals with vocal disorders,
      • Roy N
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      • Thibeault S
      • et al.
      Voice disorders in teachers and the general population.
      is similar to that presented by Brazilian teachers, a group whose profession historically indicates the presence of great symptomatology and vocal risk.
      • Behlau M
      • Zambon F
      • Guerrieri AC
      • et al.
      Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects.
      Individuals who used oxygen therapy had a higher frequency of vocal signs and symptoms after COVID-19. The prescription of oxygen therapy is widely described in the literature to treat respiratory failure as it improves O2 supply to cells by increasing the partial pressure of oxygen in the arterial blood through a higher oxygen concentration in the inspired air.
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      One of the side effects of this type of therapy is the dryness due to inadequate humidification.

      SOCIEDADE BRASILEIRA DE PNEUMOLOGIA E TISIOLOGIA. Oxigenoterapia domiciliar prolongada (ODP). J Pneumol. 2000;26:341-350. doi:10.1590/S0102-35862000000600011

      Dryness of the mucous membranes of the vocal tract can be hypothesized as a cause, and dehydration may increase vocal symptomatology.
      Individuals with vocal complaints after COVID-19 also had a higher frequency of vocal signs and symptoms. This result was expected, and there is already a consensus on this aspect in the literature.
      • Rodrigues G
      • Zambon F
      • Mathieson L
      • et al.
      Vocal tract discomfort in teachers: its relationship to self-reported voice disorders.
      • Lucchini E
      • Ricci Maccarini A
      • Bissoni E
      • et al.
      Voice improvement in patients with functional dysphonia treated with the Proprioceptive-Elastic (PROEL) method.
      • Moghtader M
      • Soltani M
      • Mehravar M
      • et al.
      The relationship between vocal fatigue index and voice handicap index in university professors with and without voice complaint.
      This study presented a risk of memory bias due to data collection performed after COVID-19 from the moments before and during the disease. For a better understanding of the theme, studies with longitudinal follow-up of patients after COVID-19 in monitoring vocal symptoms and clinical data of auditory-perceptual, acoustic, aerodynamic, and laryngological evaluations are suggested; analysis of vocal data of COVID-19 patients submitted to invasive mechanical ventilation; and investigation of the effects of speech therapy and its association with respiratory physiotherapy on patients’ vocal rehabilitation after COVID-19.

      CONCLUSION

      Individuals affected by COVID-19 have a higher frequency of signs and symptoms during the disease; however, they still maintain a higher frequency than baseline after remission. The most reported vocal signs and symptoms during and after COVID-19 indicate a relationship with pulmonary sequelae and upper airway, and vocal symptoms commonly present in the acute phase of the disease. The need for oxygen therapy may indicate a risk for a higher occurrence of after COVID-19 vocal signs and symptoms.

      Declaration of Competing Interest

      There are no conflicts of interest to declare.

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