Compared to the general population, teachers are at a heightened risk of developing voice disorders. In these slides, we review some of the recent evidence about likely contributing factors, and steps teachers can take to reduce their risk of developing voice disorders.

1. Teachers:
voice disorders
(and what to do
about them)

2. Hello!
David Kinnane
Speech pathologist, lawyer, son of teachers, local dad.

3. “The human voice: It’s the
instrument we all play. It’s the
most powerful sound in the
world, probably. It’s the only
one that can start a war or say
‘I love you’. And yet many
people have the experience
that when they speak, people
don’t listen to them.”
Julian Treasure

4. 1. What do we mean by “voice disorder”
(also called “dysphonia”)

5. “Voices are like fingerprints,
from Cagney to Bogart…My
voice is instrumental in
categorising me.”
Sylvester Stallone

6. Lots of definitions
■ “A voice disorder exists when the
quality, pitch, loudness, or flexibility
differs from the voices of others of a
similar age, sex and cultural group”
(Aronson, 1985)
■ The “abnormal production and/or
absences of vocal quality, pitch,
loudness, resonance, and/or
duration, which is inappropriate for
an individual’s age and/or sex”
(ASHA, 1993)
■ “Problem with your voice that
prevents you from doing all that you
wanted to do with it” (de S. Leao et
al., 2014)

7. Common signs
■ Roughness
■ Strain
■ Breathiness
■ Too high/low in pitch
■ Pitch breaks
■ Monotone
■ Too loud, or too soft
■ “Glottal fry”
■ Voice cuts out while speaking
■ Loss of voice
■ Tremor
Can happen alone or together, in
combination.

8. 2.
Teachers are at heightened risk of
developing voice disorders

9. Teachers are heavy voice users
■ Several jobs require effective oral
communication – 1/3 of the work
force use voice as their primary tool.
■ Teachers are one of the largest
groups who depend greatly on their
voices for work.
■ Teachers need their voices to be
flexible, resilient and clear for
teaching.
Sources: de S. Leao et al., 2015; Cantor Cutiva
et al., 2013

10. Teachers are at higher risk of voice disorders
■ General population: 3-9% in the US,
~4% in Australia (Verdolini et al.,
2001)
■ Up to 90% of teachers encounter some
symptoms of voice disorders (Marks,
1985).
■ 20-80% of teachers develop a voice
disorder (Hazlett et al., 2009)
■ More than half of teachers experience
a voice disorder during their career
(Van Houtte et al., 2011)

11. Teachers are at higher risk of voice disorders
■ 2013 systematic study: 15-80% of
teachers reported voice problems over
a 12 month period
■ 2015 NZ study on 1,879 teachers
found:
□ 33.2% developed a voice disorder
at some point in their careers.
□ 24.7% had a voice disorder in the
year of study;
□ 13.2% had a voice disorder on the
day of the survey.
Sources: Cantor Cutiva et al., 2013; de S Leao et al., 2015.

12. Teachers are at higher risk of voice disorders
■ Compared to others, teachers more
susceptible to:
□ losing their voices (aphonia)
□ edema (vocal fold swelling)
□ vocal fold nodules
Source: Van Houtte et al., 2011.

13. 3.
Effects of voice disorders

14. “Words mean more than what
is set down on paper. It takes a
human voice to infuse them
with deeper meaning.”
Maya Angelou

15. Global health problem.
Voice disorders inflict:
■ Educational costs – lesser quality of
teaching.
■ Financial costs, e.g. costs of sick
leave, casual teachers.
■ Mental health costs, e.g. feelings of
hopelessness, anxiety, depression.
■ Personal costs: can threaten, shorten
or even end a teacher’s career.
Affects individual teachers and their
families, students, community, and
employers.
Sources: de S. Leao et al., 2015; Van Houtte et al., 2011

16. 4.
Why does it happen?

17. Likely contributing /risk factors:
■ Intense and prolonged voice use
■ Inefficient voicing techniques –
phonotrauma, vocal abuse
■ Background noise/bad acoustics –
above 50 decibels (some classrooms
measured at above 85 decibels)
■ Primary teachers more at risk
■ Type of teaching, especially sports
■ Class sizes (mixed evidence)
■ Stress and long hours without rest
■ Poor climate conditions, e.g. dry air,
dust, smoke, temperature changes
■ Age (very young and older teachers
at risk)

18. Likely contributing/risk factors:
■ Years of teaching/
cumulative voice use
■ Caffeine, alcohol, illegal drugs
■ Smoking
■ Allergies
■ Upper airway infections
■ Gastroesophageal reflux
■ Habitual throat clearing
■ Chronic cough
Sources: Hazlett et al., 2009; Van Houtte et al., 2011; Regina
Boaia Neves Pereria et al., 2015

19. Why are women more at risk of voice
disorders?
■ Traditionally ascribed to
psychological reasons.
■ But physical reasons play a big
factor – cf. men, women:
■ have shorter, lighter vocal folds
(cords)
■ produce voice at a higher pitch
■ have less tissue mass to absorb
high number of vibrations
■ have less hyaluronic acid in top
layers of vocal folds – reduced
wound healing
Source: Van Houtte et al., 2011.

20. Reality check: many risk factors hard to
change
■ Attention should focus on
prevention through education.
■ Two main elements:
■ Vocal hygiene training
■ Vocal function exercises to
voice efficiently

21. 5. (Very) basic overview of
how the voice works

23. A picture is worth a
thousand words
Source:
http://training.seer.cancer.gov

24. Teachers at risk of developing
“hyperfunctional voice problems”
■ Too much yelling - leads to voice
deterioration – often hoarseness,
loss of voice and loss of vocal range
– also called “vocal abuse”
■ Can lead to the development of
functional disorders (inefficient use
of the voice box)
■ Over time, can lead to organic
disorders, e.g. vocal nodules
Source: Van Houtte et al., 2011.

25. Source: http://www.ohniww.org/vocal-nodules-diagnosis/

26. Source: http://www.ohniww.org/vocal-nodules-diagnosis/

27. 6. Simple vocal hygiene program for
teachers

28. Instead of clearing your throat or coughing
habitually…
■ Yawn
■ Swallow
■ Sip water
■ Push air up from your lungs in short,
quiet bursts (“silent giggle”)
■ Suck on lollies (not cough drops with
menthol or mint)
■ Hum

29. Instead of yelling…
■ Use gestures
■ Clap
■ Whistle, ring a bell, blow a horn
■ Set up a system of non-vocal signals
with students to get attention
■ Walk up close to a student who
needs discipline and speak to
him/her quietly.

30. Instead of shouting over background noise…
■ Consider personal amplification
devices: ~13dbls (more in the
playground).
■ Wait until students are quiet and
attentive
■ Face the students
■ Reduce the distance between you
and your students
■ Make sure your face is well lit
■ Over-articulate – mouth open wide,
slow down speech
■ Use lulls in noise to speak

31. Instead of shouting over background noise…
Example of a personal amp
~$100.
Source:
https://www.thincproducts.com.
au/product-page/black-betty-
wireless-microphone

32. Instead of straining for breath and voice
■ Pause more often and keep
sentences shorter
■ Avoid gasping. Take more breaths
between phrases
■ Allow your pitch to vary, but within
comfortable range
■ Don’t hold your breath before you
speak
■ Reduce your “ums” and “ahs”
■ Initiate voice easily on words starting
with vowels, e.g. “apple”, “each”
■ Keep shoulders, upper chest and
throat relaxed
■ Let your abdomen and ribs move
freely
■ Avoid clenching your teeth or tensing
your jaw/tongue during speech

33. Healthy body, healthy voice
■ Don’t smoke
■ Avoid recreational drugs
■ Cut down on caffeine
■ Reduce alcohol
■ Balanced diet
■ Get enough sleep – 7 hrs+
■ Maintain humidity – e.g. vaporiser
■ Maintain proper hydration – 8-10
glasses of water a day
■ Increase water if taking
antihistamines or decongestants
■ Control reflux with anti-reflux meds
■ Meditate and exercise for general
stress management

34. Other tips
■ Rest your voice when you have a
cold/flu or laryngitis
■ Schedule periods of voice-rest during
the day (e.g. silent lunches)
■ Mix up teaching style – use
audiovisual materials, desk work,
student presentations, and small
group formats to reduce need for
constant speech.
■ Use teaching aides, volunteer
parents and student teachers, and
student leaders wherever possible
Sources: Roy et al., 2001; Martin & Darnley, 2006; La Trobe
Communication Clinic.

35. 7. Simple voice exercises

36. “The human voice is the most
beautiful instrument of all, but
it is the most difficult to play”
Richard Strauss

37. Main principles
■ Twice a day, morning and evening
■ Practice softly, voice is clear but not
breathy
■ Place the tone forward, with
constricted “buzzy” lips and/or
vibrating face
■ Focus not on voice box, but on the
feeling of vibrations on your lips/front
of your face

38. Exercise 1: Yawn-Sigh
■ Aim: to “reset” the voice to optimal
voicing settings, lower the voice box
and reduce strain.
■ How to do it:
□ Simulate a relaxed “Papa Bear
yawn”, followed by a sigh
□ Repeat 5 times
□ Yawn-sigh into “ha”, “hu”,
“hee”, “hoe”
□ Yawn-sigh into “hello”, “here”,
“happy”, “highlight”
□ Yawn-sigh into phrases
□ Gradually, phase out the Yawn-
sigh but keep the relaxed
larynx.

39. Exercise 2: Gentle Stretching exercise
■ Aim: no voice breaks.
■ How to do it:
□ Glide upwards from your lowest
note to your highest, using the
word “knoll” or “whoop” or a lip
trill
□ Glide downwards from your
highest to lowest note using the
word “knoll” or “boom” or a lip
trill.

40. Exercise 3: Low impact adductory power
exercise
■ Aim: efficient voicing – vocal folds
gently touching or gently separated.
■ How to do it:
□ Quietly, sustain the musical
notes C-D-E-F-G for as long as
possible.
□ Use the word “knoll” but minus
the “kn”.
□ Sources: La Trobe Communication Clinic;
Roy et al., 2001.

41. Important note:
■ This is a high level, general overview
only. It is not medical or health
advice!
■ In addition to vocal abuse, lots of
things can cause voice problems –
and some voice disorders are more
serious than others.
■ If you experience painful, recurrent,
or prolonged voice problems, or if
your voice deteriorates, we
recommend that you consult with an
Ear, Nose and Throat Specialist and
Speech Pathologist.

42. Thank you for having me!
Any questions?
You can find me at @speechbloke (Twitter) and
david.kinnane@banterspeech.com.au

43. SELECTED REFERENCES
Leão, Sylvia H. de S, Oates, J. M., Purdy, S. C., Scott, D., & Morton, R. P. (2015). Voice problems in New Zealand teachers: A national survey. Journal of Voice, 29(5), 645.e1-645.e13.
doi:10.1016/j.jvoice.2014.11.004
Cantor Cutiva, L. C., Vogel, I., & Burdorf, A. (2013). Voice disorders in teachers and their associations with work-related factors: A systematic review. Journal of Communication Disorders, 46(2), 143-
155. doi:10.1016/j.jcomdis.2013.01.001
Hazlett, D. E., Duffy, O. M., & Moorhead, S. A. (2011). Review of the impact of voice training on the vocal quality of professional voice users: Implications for vocal health and recommendations for
further research. Journal of Voice, 25(2), 181-191. doi:10.1016/j.jvoice.2009.08.005
Martins, R. H. G., Pereira, Eny Regina Bóia Neves, Hidalgo, C. B., & Tavares, E. L. M. (2014). Voice disorders in teachers. A review. Journal of Voice, 28(6), 716-724.
doi:10.1016/j.jvoice.2014.02.008
Masson, M. L. V., & de Araújo, T. M. (2017). Protective strategies against dysphonia in teachers: Preliminary results comparing voice amplification and 0.9% NaCl nebulization.Journal of
Voice, doi:10.1016/j.jvoice.2017.04.013
Pereira, Eny Regina Bóia Neves, Tavares, E. L. M., & Martins, R. H. G. (2015). Voice disorders in teachers: Clinical, videolaryngoscopical, and vocal aspects. Journal of Voice, 29(5), 564-571.
doi:10.1016/j.jvoice.2014.09.019
Roy, N., Gray, S. D., Simon, M., Dove, H., Corbin-Lewis, K., & Stemple, J. C. (2001). An evaluation of the effects of two treatment approaches for teachers with voice disorders: A prospective
randomized clinical trial. Journal of Speech, Language, and Hearing Research, 44(2), 286-296. doi:10.1044/1092-4388(2001/023)
Ziegler, A., Gillespie, A. I., & Verdolini Abbott, K. (2010). Behavioral treatment of voice disorders in teachers. Folia Phoniatrica Et Logopaedica, 62(1-2), 9-23. doi:10.1159/000239059
Van Houtte, E., Claeys, S., Wuyts, F., & Van Lierde, K. (2011). The impact of voice disorders among teachers: Vocal complaints, treatment-seeking behavior, knowledge of vocal care, and voice-
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Russell, A., Oates, J., & Greenwood, K. M. (1998). Prevalence of voice problems in teachers. Journal of Voice - Official Journal of the Voice Foundation, 12(4), 467-467. doi:10.1016/S0892-
1997(98)80056-8

44. Credits
Special thanks:
■ Presentation template by SlidesCarnival
■ Photographs by Death to the Stock Photo (license)
■ Diverse device hand photos by Facebook Design
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