The silent treatment

Imagine trying to do your job without your voice. Think about how differently you would behave, how differently people would behave towards you, and the barriers you would need to overcome. No-one deliberately damages their voice, and until recently, relatively little attention has been paid to the prevention and management of voice disorders in the workplace. But this is slowly changing.

Studies in the US estimate that approximately 25% of the working population consider their voice as critical to performing their jobs.1 Within the general population of the US, between 3% and 9% of people will report a voice abnormality at any one time.2 Other studies have suggested rates of between 0.65% in a study involving students3, and as high as 15% in a study of the elderly.4

Groups at risk
From the range of studies, however, we can conclude that voice problems are common in the general population and occur in both the young and the elderly. It is important to note that Coyle and colleagues5 found that retired people and homemakers were two of the most common groups presenting symptoms at voice clinics.

Other ‘occupations’ frequently reported as attendees of treatment clinics are teachers, singers and actors. This is not necessarily because their voice problem was caused by their work, but because their ability to do their job would be significantly impaired if they had a voice problem.

The reported prevalence of voice problems among teachers in studies carried out in schools depends on whether the diagnosis is based on objectively diagnosed vocal cord pathology, or on subjective symptoms. Studies have reported prevalence rates of 4.4%6 and 90%7. In the latter study, Smith and colleagues7 found that:

  • 47.5% of teachers complained of hoarseness compared with 21.3% of controls. Teachers had an average of almost two symptoms, compared with none in other occupations
  • 20% of teachers reported time off work compared with 0% of non-teachers
  • 4.2% of teachers said that the voice problem was significant enough for them to consider a change of occupation.

In other studies, women were found to have a higher probability of reporting voice problems compared with men8 and teaching physical education presented the highest risk of voice disorder, independent of gender, hours of teaching per day, numbers of years teaching or age.

Preciado8 found that the numbers of teachers complaining of voice problems were highest among nursery teachers (36.4%), then elementary (25%) and lowest among junior schools (20.8%). Other factors associated with an increased frequency of vocal disorders were the physical size of the classroom, larger student numbers, longer classroom hours and higher noise levels.

Compared with teachers, relatively little has been published about this occupational group. Jones et al9 found that they were twice as likely to report one or more symptoms of vocal over-use (such as sore throat or hoarseness) compared with controls after adjusting for age, sex and smoking. Thirty-one per cent of those surveyed reported that their symptoms affected their work. Women, smokers and those who used drying medications, such as anti-histamines taken for hay-fever, reported the most symptoms.

This study is important, as telemarketers often work in call centres – an environment where concern has been expressed over the occurrence of voice disorders caused by vocal over-use.

The symptoms of voice over-use are a sore throat, a weak voice, total loss of the voice and hoarseness. Constant clearing of the throat and throat tightness can also be reported. One or more symptoms may be present, and there may be co-existing signs and symptoms of respiratory illness, as one of the most common causes of voice problems is a cold, or other respiratory infection.

It is very important that anyone who complains of hoarseness which persists for more than two weeks is referred to their GP – particularly if they are a smoker – to exclude the possibility of laryngeal cancer.

There are a variety of conditions that can affect the voice. With over-use, pathology such as nodules can develop on the vocal folds, which are particularly prevalent among singers and professional voice-users. Laryngeal cancer should always be suspected among older people – particularly smokers – but in the majority of voice over-use cases, there is no visible pathology on clinical examination.

Risk factors
Risk factors for developing voice problems include age (they are more common among older people), gender (women report more symptoms than men), the use of drying medications (such as anti-histamines) and repeated shouting or voice projection. Dehydration is also a well-recognised factor, and the benefits of adequate hydration have been shown both in the laboratory and in the workplace. In rare cases, neck surgery, particularly on the thyroid, can cause nerve damage.

The prevention of such disorders requires:

  • Organisation of work tasks to avoid vocal over-use
  • Short scripts for sales people, punctuated with rests/pauses
  • Adequate breaks away from talking on the telephone or in the classroom
  • Quiet, well-arranged work environments to prevent shouting to colleagues and customers
  • Working in a smoke- and pollution-free atmosphere with adequate humidity and warmth
  • Education on the importance of good vocal hygiene – avoiding shouting and over-use
  • Emphasis on the importance of adequate hydration and the avoidance of drinks containing caffeine, such as tea and coffee, which can promote dehydration
  • Understanding and co-operating with an early reporting system for voice problems.

Diagnosis and management
The diagnosis of the cause of a voice disorder is usually made on the clinical history and examination, the exclusion of pathology, and the findings of an assessment by a speech/voice therapist.

Individuals with symptoms and vocally demanding occupations should be encouraged to report their symptoms early. Work may need to be adapted to be less vocally demanding, through shorter periods of talking, more breaks or relocation to ‘back-office’ functions. They should be advised to continue to talk and not to whisper or remain silent. Persisting or recurrent symptoms require specialist referral to an NHS or private voice clinic, where usually an ENT surgeon and a voice/speech therapist will assess the individual. A treatment plan can then be developed which often consists of vocal exercises, and training on relaxation and breathing techniques.

The OH practitioner needs to review the individual and recognise that adaptations may be needed to help rehabilitation. Environmental noise levels in the workplace may need to be reduced – for example, by altering the work from outbound sales to handling inbound booking-type calls, or rearranging work teams so that they all sit together, rather than at disparate corners of a room. The importance of hydration also needs to be emphasised.

Managing voice problems at work is much easier if there is a voice health policy in place, and if induction and health and safety training includes the basic principles outlined above. The voice is delicate. It is specifically designed for use, but not for abuse. The loss of vocal power can be disabling as well as job threatening, so time and effort spent on its prevention is time well spent.

Nerys Williams is a consultant OH physician

Further resources
Occupational Voice Loss by N Williams and P Carding, published by Taylor and Francis 2005. It includes voice health policy samples and suggested contents for induction programmes with guidance on the prevention and management of voice problems in the workplace.

Useful websites

  • National Center for Voice and Speech. This US-based website contains some self-directed tutorials on various aspects of voice health
  •  A free self-directed ‘school’ for teachers to help them maintain good voice health

1. National Centre for Voice and Speech (1993) Occupational and voice data. National Centre Iowa City IA US
2. Ramig L O, Verdolini K (1998) Treatment efficacy; voice disorders, Journal of Speech Language Hearing Research, 41: pp101-106
3. Morely D E (1952) A Ten-Year Survey of Speech Disorders Among University Students, Journal of Speech Hearing Disorders pp25-31
4. Laguaite J K (1972) Adult Voice Screening, Journal of Speech Hearing Disorders 37: pp147-151
5. Coyle S M, Weinrick B D, Semple J C (2001) Shifts in Relative Prevalence of Laryngeal Pathology in a Treatment Seeking Population, Journal of Voice, 15: pp424-440.
6. Marks J B (1985) A comparative study of voice problems among teachers and civil service workers, Masters thesis, University of Minnesota, Minneapolis, US
7. Smith E, Gray M, Dove, S, Kirchner L, Heras H. (1997) Frequency and Effects of Teachers’ Voice Problems, Journal of Voice 11: pp81-87
8. Preciado J A, Garcia Tapia R, Infante J C, (1998) Prevalence of voice disorders among educational professionals. Factors contributing to their appearance or their persistence, Acta Otorrinolaringology Espania, 49(2) : pp137-142
9. Jones K, Sigmon J, Hock L, Nelson E, Sullivan M, Ogren F (2002) Prevalence and risk factors for voice problems among telemarketers,
Archives of Otolaryngology, Head and Neck Surgery 128 (5) pp571-577

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