ISSUES RELATED TO PROFESSIONAL VOICE AND ITS CARE

SUBMITTED TO, SUBMITTED BY,

Mr. NARASIMHAN SIR SHIVAM SINGH

LECTURER MASLP FIRST YEAR

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 CONTENTS

1. INTRODUCTION
2. VOICE DISORDERS IN PROFESSIONAL VOICE USERS
3. SIGNS AND SYMPTOMS AS A CLUE TO ETIOLOGY
4. VOICE PROBLEMS IN SINGERS:
i. Common Pathological Condition In Singers:
ii. Poor Posture
iii. Symptoms
5. VOICE PROBLEMS IN TEACHERS:
i. Symptoms
6. VOICE PROBLEMS IN ACTORS:
7. VOICE PROBLEMS IN CHEERLEADERS:
8. VOICE PROBLEMS IN ARMY COMMANDERS:
9. VOICE PROBLEMS IN INDUSTRIAL WORKERS:
10. VOICE PROBLEMS IN OTHER PROFESSIONALS:
11. ASSESSMENT
i. Need Of Assessment:
ii. Assessment In Singers
iii. Assessment In Actors
iv. Assessment In Teachers
12. GENERAL ASSESSMENT
i. Detailed Case History

ii. Physical Examination

iii. Subjective Evaluation

iv. Objective Evaluation

13. CARE OF PROFESSIONAL VOICE USERS
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 INTRODUCTION
There is an ever increasing segment of the population which is dependent on vocal
endurance and quality for their livelihood. The use of voice for the specific professional
performances varies greatly with the content and purpose of verbal communication. The
term professional voice user will be arbitrarily limited to individuals who use the voice
extensively for some form of artistic expression, in other words, to performers. Anyone
who needs their voice in order to carry out their job is considered a professional voice
user. Professional voice users are those individuals who are directly dependent on vocal
communication for their livelihood -
Stemple, 1991
Professional voice users are also often considered ‘athletic’ voice users because their
voice use is more extensive and strenuous than that of a non-professional voice user
- Khambato, 1979
Professional voice users of three types:
 Those who use their voice of a long period of time (politicians, teachers,
telephone users)
 Those who use their voice under adverse circumstances persons working in noisy
environments (Factory workers, sports arenas)
 Those who use their voice for special purpose (singer, theater artists)
Professional voice users include:
 Singers
 Actors
 Teachers
 Salespersons
 Clergy
 Coaches
 Broadcasters
 Auctioneers
 Choreographers and many others

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 Koufmann & Isaacson (1991) evolved a classification of vocal professional based on
their voice use and risk.
 Level I: The elite vocal performer
- professional singers and actors for who even slight aberration of voice may cause
serious consequences.
- Members of this group require maximum vocal performance in all parameters.
- They are sometimes referred to as vocal athletes because of the superior quality,
pitch range and loudness that they are able to achieve.
 Level II: The professional voice user
- for whom moderate vocal problem might prevent adequate job performance e.g.
Teacher, Telephone Operator, Barristers, Clergy.
- They frequently require considerable vocal stamina over prolonged periods and in
many cases have to make themselves heard by large group of listeners.
- If affected by aphonia or dysphonia, would be discouraged in their job and seek
alternative employment (Titze etal, 1997).
- Even low levels of vocal impairment is not able to perform the job adequately.
 Level III: Non-vocal professional – this include doctors, business executives and
lawyers, for whom a severe vocal problem would prevent adequate job performance.
 Level IV: Non-vocal non-professional – for whom vocal quality is not a pre-
requisite for adequate job performance e.g. clerks, labourers.

VOICE DISORDERS IN PROFESSIONAL VOICE USERS

Sataloff (1991) considers the causes of voice disorders in professional voice users as
follows:
 Misuse and abuse: poor singing/ speaking techniques, singing out of range,
chronic coughing, throat clearing, smoking, poor hydration, overuse of voice.
 Chronic medical problems: esophageal reflux, allergies, sinusitis, upper
respiratory tract infection, poor diet, fatigue, illicit drug uses.
 Environmental factors: performing in dry, smoky environment, exhaustive
schedule, poor acoustics, loud music.
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  Emotional factors: stage fright, anxiety, depression, performance stress.
Vocal misuse and abuse are the predominant factors leading to voice problems in
vocations involving high demands on the vocal mechanism
- Sapir, 1992
Other problems that are seen among professional voice users
Vocal attrition-laryngeal tissue pathology, muscle fatigue and voice disorders
secondary to acute or chronic or misuse of the secondary vocal mechanism (Sapir,
1992). Hyperkinetic which means excessive expenditure of energy in muscular
movements with regards to voice production.
SIGNS AND SYMPTOMS AS A CLUE TO ETIOLOGY
 Vocal fatigue – suggests musculoskeletal issue (misuse of abdominal or neck
musculature) and may point to over singing or overuse of voice. Neurological problems
may also present to this complaint. Prolonged warm-up time – considered a problem in
western singers. This refers to the time that singers need to warm up their voice while
initiating a session of singing (usually morning times). Frequently associated with
reflux (Sataloff, 1991).
 Pain – May be due to vocal abuse, as are choking or coughing.
 Harsh voice with loss of dynamic range – May be associated with vocal polyps,
Reinkes edema or other mass lesions (Hibis et al. 1990).
 Breathiness – May be indication of vocal fold palsy or other problems preventing
closure of the vocal folds (Sataloff R.T. 1997).
Voice weakening especially in association with increased nasality could be indicative of
myasthenia gravis (Catten et al. 1990).Volume disturbance is characterized by an
inability to sing loudly or softly.
VOICE PROBLEMS IN SINGERS:
Singing involves a more prolonged and sustained voice production while speaking
involves a series of transient sounds.
Singing undoubtedly involves a more sophisticated and controlled way of voice.
The physical demands on a singer can be very great if one considers the energy needed
in performance as well as the wearing life style inherent in the profession
The singing voice employs much more extensive pitch & loudness range than speaking.

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To achieve very high notes, subglottic air pressures are much higher and in trained
singers the closed quotient of each vocal fold vibratory cycle is longer (Carroll.et.al,
1996).
In the teaching of singing, the mastery of special singing techniques is essential.
Covered voice:
In western European classical singing, the means of increasing vocal substance and a
swelling tone
A slight ‘darkening’ of the vowels on higher pitch levels to avoid excessively bright
timbre in singing (Luchsinger 1965)
Lip rounding is essential in achieving covered voice because all formant frequencies
decrease uniformly with lip rounding and with increased length of the vocal tract (Titze,
1994b).
It is also used to facilitate changes from one register to another.
Sundberg (1995) termed singers formant i.e. fusion of 3 rd and 4th formants of the
fundamental note.
The combination of these peaks of resonance results in a band of maximum energy in
the region of 2500 – 3000 Hz.
The singer’s formant is most likely to occur at high Fo and intensity (Hollien, 1980).
Sundberg (1974) also provide an articulatory interpretation of singing formant.
In male singers, the envelope peak is in the region of 2.8 KHz and in order to achieve
this, 3 conditions of the vocal tract have to be met:
Cross sectional area must be atleast 6 times wider than the laryngeal tube orifice. If
mismatched an extra formant is added.
Laryngeal ventricle must be wide in relation to the larynx tube and if mismatched an
extra formant may be added between the third and fourth formants of normal speech.
Pyriform fossa must be wide, which reduces the fifth formant to about 3 KHz.
Vibrato:
Skill used by singers to add emotion and beauty to the voice.

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It varies according to the type and culture of singing, giving Western operatic singing its
warm, rich tone.
A Fo modulation occurs at a rate of 5-7 Hz over a range of 1 semitone.
In popular singing and in non western cultures, the vibrato quality appears to develop
from pulsations of sub glottic air pressure rather than pulsations of cricothyroid muscle
(Sundberg , 1974).
The rate of vibration is faster in females than males and tends to accelerate under the
influence of emotion. When properly controlled, vibrato enhances the singing voice.
Ramig & Shipp 1987 compared vibrato features of opera singers with the vocal
characteristics of patients with pathological vocal tremor, there were only minor
differences between the 2 groups. The regularity of the Fo variation was somewhat
greater in singers, the vibrato rate in singers was 5.5 Hz compared with the vocal tremor
patients who produced a rate of 6.8 Hz
Trill:
It is achieved by rapid variation of pitch between a base note and a note higher by either
a whole tone or a semitone (Titze, 1994).
Vennerd.et.al (1967) submitted trills of 4 outstanding sopranos to spectrographic
analysis.
- the rate of pitch fluctuation in a trill is less faster than that of a vibrator
- the extent of the pitch variation is increased so that the ear can perceive the 2
pitches involved.
Rhythmic contractions of the whole laryngeal structure accompany a trill, but the visible
movement of the larynx has no connection with the wobble voice quality resulting from
excessively slow vibrato.

Yodel:
It is a particular style of singing that consists of sudden jumps in pitch from modal to
falsetto voice on vowel sounds only, not words.
Good air support is necessary and this is provided by activity of diaphragm.

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Perfect singing techniques will greatly improve a mediocre voice and enhance an
excellent voice.
COMMON PATHOLOGICAL CONDITION IN SINGERS:
Laryngitis
Dehydration & lubrication
Reflux laryngitis
Vocal fold nodules
Vocal polyp
Vocal fold cyst
Sulcus vocalis
In dealing with the physical production of the singing voice, one encounters many
problems, all of which are interrelated, and often addressed simultaneously. These
problems are prevalent in different types of singers, regardless of training and
experience.
Poor Posture
The efficient alignment of the body is of primary importance to voice production.
Problems in posture range from "collapse" of the chest and rib cage, with corresponding
downward "fall" of the head and neck, to the hyper-extended, "stiff" posture of some
singers, that results in tension throughout the entire body.
 Poor Breathing and Inappropriate Breath Support
Some beginning voice students seem to "gasp" for air, and exhibit clavicular or shallow
breathing patterns while trained singers, on the other hand, use primarily diaphragmatic
breath support.
The muscles of the lower back and abdomen are consciously engaged, in conjunction
with lowering of the diaphragm.
As the breath stream is utilized for phonation, there should be little tension in the larynx
itself.
Sometimes, in an attempt to increase loudness (projection), a well-trained singer may
over- support or "push" the airstream.

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This extra effort may affect vocal quality by producing undesirable harmonics.
 Hard Glottal or "Aspirate" Attack
"Attack" or "onset" (a preferable term for singers) occurs with the initiation of
phonation.
Some singers (possibly related to poor speech habits) use a glottal attack, which is too
hard (produced by to much tension in closure, hyper adduction).
Vocal cord nodules may develop with habitual use of a hard glottal attack.
The opposite problem is the "aspirate" attack, in which excessive air is released prior to
phonation.
While this type of attack rarely damages the vocal cords, it causes a breathy tone
quality. (This technique may, however, be utilized to help correct a hard glottal attack).
 Poor Tone Quality
Many terms are commonly used to describe a singer's tone - clear, rich, resonant,
bright, dark, rough, thin, breathy, and nasal.
"Good tone" is highly subjective, according to the type of singing and personal
preference of the listener, in general, a tone that is "clear" (without extra "noise") and
"resonant" (abundant in harmonic partials) is acknowledged as "healthy" and naturally
will have sufficient intensity for projection without electric amplification.
Opera singers strive to develop a "ring" (acoustic resonance at 2,500-3,000 Hz), that
enables the voice to project over a full orchestra, even in a large hall.
However, for other styles of singing, the use of amplification may allow a singer the
choice of employing a less acoustically efficient vocal tone for reasons of artistic
expression.
A breathy tone, for example, may be perceived by the listener as "intimate", and even a
"rough" sound, such as was used by Louis Armstrong (false vocal cord voice), may
represent the unique persona of a performer.
 Limited Pitch Range, Difficulty in Register Transition
All singing voices exhibit an optimal pitch range.
Typically, untrained voices have narrower pitch range than trained singers, due to lack
of "register" development.

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The term "register" is used to describe a series of tones that are produced by similar
mechanical gestures of vocal fold vibration, glottal and pharyngeal shape, and related
air pressure.
Some common designations of registers are the "head" register, "chest" register,
"falsetto", etc.
Singing requires transitions from one register to another; each of these transitions is
called a "passaggio" ("passageway").
Lack of coordination of the laryngeal musculature with the breath support may result in
a "register break", or obvious shift from one tone quality to another.
Untrained male voices and female voices tend to "break" into falsetto/head voice in the
upper range.
Regardless of the style of singing, a "blend", or smooth transition between the registers
is desirable.
 Lack of Flexibility, Agility, Ease of Production, Endurance
Traditional voice training places emphasis on vocal flexibility or agility for example,
the singer's ability to execute rapid scales.
Virtuosic technique demands excellent aural conceptual ability, coordination of an
abundant airstream with energetic diaphragmatic support and clear, resonant tone
quality.
The use of rapid melodic passages in vocal training helps to develop a relaxed, yet vital
voice production that contributes to the development of increased vocal endurance.
 Poor Articulation
Pronunciation with excessive tension in the jaw, lips, palate, etc., adversely affects the
tonal production of the voice.
Problems of articulation also occur when singers carry certain speech habits into
singing.
The longer duration of vowel sounds in singing necessitates modification of
pronunciation (the increased "opening" of certain vowels in the high soprano voice, or
elongation of the first vowel in a diphthong.)
Retroflex and velar consonants (such as the American "r" and "l") need careful
modification to allow sufficient pharyngeal opening for best resonance, and the over

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anticipation of nasal consonants ("m", "n", "ng") may result in a "stiff" soft palate and
unpleasant tone.
 Lack of Discipline, Commitment, Compliance
regular practice is essential for optimal development and performance.
Unfortunately, the need for disciplined training is not always apparent to singers.
"artistic temperament" may contribute to a lack of compliance with the advice of
teachers on issues of vocal technical development.
When a teachers advice is contrary to a singer's own established ideas and work habits,
the singer may tend to overwork, overperform, or simply "try too hard" in practice.
The singer's practice and performance regimen must be sensible, productive, and
acceptable to both teacher and student alike.
 Poor Health, Hygiene, Vocal Abuse
Many singing students ignore good vocal hygiene.
The physical demands of singing necessitate optimal health, beginning with adequate
rest, aerobic exercise, a moderate diet (and alcohol consumption), and absolute
avoidance of smoking.
Many singers are careful with their voices but abuse their voice by employing poor
speaking technique
Professional singers who travel are frequently confronted with changes in their sleep
and eating patterns. (Specifically, singers should avoid talking excessively on airplanes
that are both noisy and dry).
Performing in dry or dusty concert halls increases the risk of vocal fatigue and infection.
A minor cold or allergy can be devastating to a professional singer, who is obliged to
perform with swollen (edematous) vocal cords
Good vocal hygiene, good travel habits, and vigilant protection of ones instrument
(good judgment) is an important responsibility of every singer.
 Poor Self-Image, Lack of Confidence
Many singers appear to have "healthy egos" and may display the aggressive behavior
which is a cover-up for anxiety and/or insecurity.

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Since the slightest aberration - phlegm, for example - can result in momentary loss of
voice (even in the greatest of performers), singers often feel that they are always in a
state of vulnerability.
Despite unpredictability in vocal performance, the singer does gain confidence through
repeated performance and increased self awareness.
SYMPTOMS:
The typical voice problems complained by the singers includes:
 Hoarseness
 Inability to continue to sing for extended periods of time
 Difficulty in producing high or low tones which they were capable of doing
earlier.
 Vocal fatigue by becoming hoarse, losing range, changing timbre, breaking into
different registers or exhibiting other uncontrolled aberration (Sataloff, 2000), volume
disturbance, prolonged warm-up time.
Vocal abuse may leads to vocal nodules in singers also like any other professional
voice users.
The speaking voice may only be affected little, if at all it is affected, the singing voice
is usually characterized by
- Limitations of upper range
- Onset delays with high soft phonation
- Reduced vocal endurance
- Increased efffrot to sing and long warm-up time. (Bastian,1993)
Hogikyan et al. (1999) elicited opinions of a large group of ENT, SLP and Teachers of
singing on the reasons for the nodules in singer.
 Shouting
 Screaming
 Poor singing techniques
 Too loud singing

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 Style of singing
 Singing out of range
 Excessive throat clearing
 Excessive coughing
 Rehearsing when fatigued
The tendency to prolong period of tone recital for unreasonable lengths of time on a
single breath, puts a lot of pressure on the breathing mechanism and the singer in an
effort to squeeze and maintain air from lungs.
Usage of wrong force, wrong pitch or breathing can also damage the singing voice.
Perkner etal compared 3 specific types of performer – opera, musical theatre and
contemporary singers. They found a significant increase in voice disorders (44%) but no
difference was found among different styles of singers.
Reid.K.L, Davis.P et al (2007) studied members of a professional opera chorus.
Subjects sung with equal or more power in the singer's formant region in choral versus
solo mode in the context of the piece as a whole and in individual vowels.
No difference in vibrato rate and extent between the two modes.
Singing in choral mode, therefore, required the ability to use a similar vocal timbre to
that required for solo opera singing.
Sheela Kumar (1974) compared the vocal parameters between 30 trained and 30
untrained singers (19-54 yrs).
Vocal parameters were optimum frequency, Fo while phonating /a/ in the speaking
pitch, Fo while phonating /a/ in the singers pitch, phonation time, pitch range and vital
capacity.
Results:
Significant differences exist between optimum frequency and fo while phonating /a/ in
the speaking pitch.
Trained singers tend to use their optimum freq while speaking unlike the untrained
singers.

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Optimum frequency is neither used by trained singers or untrained singers while
singing.Trained singers possess significantly greater pitch range than untrained
singers.No significant difference was observed in phonation time and vital capacity
between the two groups.
Archana (1997) conducted a study to find out the behaviour of vocal folds and resultant
acoustic output in the musical notes within and across 3 registers in karnatic vocal
music using EGG and spectral paramters. Sub: 5 female trained singers (15-30 yrs).
They were asked to sing the individual notes from lowest – highest of their vocal range
sustaining each note for 1-2 s.
Opening and closing time, open and closed phase, open & speed quotient, speed index,
total period showed significant difference across the notes & registers due to marked
change in the glottal parameters across frequencies of glottal vibration. The parameters
of LTAS (α,β, & γ ratio) showed significant difference across registers but within
registers only α ratio showed significant differences.
Janani (2004) conducted a study to determine the voice changes that take place over the
years due to the developmental processes in a female professional singer for fo, f1, f2,
jitter & shimmer.
Songs sang by the singer from 12-74 yrs were collected.
The phonated vowels /a/, /i/ & /u/were extracted from the songs & analysed using
MDVP.
Fo,F1 &F2 of these vowels reduces as age advances.
Jitter % changes for all the vowels were remained 2%
Shimmer % increase with age. Maximum change was between 62-74 yrs
Conclusion:
Singers must use their optimum pitch while singing & follow a good vocal hygiene
program.
VOICE PROBLEMS IN TEACHERS:
Teachers form a large group of a professional voice users and are thought to be at risk
for voice problems compared to the general population (Fritzell, 1996; Russel, Oats &
Greenwood, 1998).
Prevalence rate of voice problems in teachers vary from 4 to 90%

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SYMPTOMS:
• Vocal fatigue
• Discomfort in the throat
• Hoarseness
• Loss of voice
• Effortful voice
• Voice spasms
• Breathy voice
Vocal fatigue is characterized as a problem that begins to occur as the speaking day
progresses is most evident at the end of the day and usually disappears by the following
morning (Voltas & Starr, 1993).
In a survey, Cooper (1973) found a high prevalence of symptoms of vocal attrition in
class room teachers.
A majority of the teachers dysphonia shows laryngeal lesions or morphological
anomalies.
Vocal abuse and misuse due to the vocal demands and poor acoustic environment in
which teachers work (Sapir, Keider & Van Venzen, 1993).
Lack of vocal education and training (Cooper, 1973) other factors like stress and
anxiety, factors related to teachers career like length and type of teaching.
Bistriski and Frank (1981) compared 37 Israeli female elementary school teachers who
had received instructions in vocal hygiene prior to becoming teachers with 40 teachers
who had not received any training.
After 2-4 yrs of teaching, of the teachers without training
- 85% reported fatigue
- 80% hoarseness
- 70% sore throat
- 42% aphonia
- 40% vocal attrition

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Shivshanker.N (1978) studied the effects of vocal fatigue on voice parameters of 40
female Indian primary school teachers (mean age =36yrs).
Voice measures of min and max Fo were obtained before and after 1 ½ hrs of continous
teaching at the work place.
Most common perceptual symptoms were throat dryness, discomfort, loss of voice and
max Fo was found to be important in determining the presence of fatigue.
Using MDVP, Gopal.S, Krishna and Nataraja.N.P (1995) studied susceptibility criteria
for vocal fatigue using 5 normals and 5 teachers.
The subjects were selected based on a questionnaire study, 2 sets of phonation before &
after the subject underwent fatiguing task of reading continuously for ½ hrs duration
It was found that ½ hr duration was sufficient to induce vocal fatigue and Fo parameters
reflect changes in the vocal system earlier than other parameters.
Gopalkrishnan (1995) studied vocal fatigue in teachers and investigated the acoustic
correlates of vocal fatigue in them.
He found the parameters sensitive to vocal fatigue to be frequency related
measurements, frequency perturbation measurements, long term amplitude perturbation
measures and noise measurements.
He also reported the major symptoms as dryness in the throat, tiring voice and talking
with effort.
Shobha Menon (1996) studied vocal fatigue in 20 primary and secondary school
teachers by administering a questionnaire and recording phonation of /a/ /i/ /u/ and
speech samples in both pre fatigue and post fatigue (6-7 hrs after teaching) condition.
She reported the major symptoms as tiring of voice, dryness of the throat, vocal fatigue,
burning sensation in the throat.
Phonation samples were audio recorded and analyzed to obtain mean, max, min, range
of frequency and intensity fluctuations per second and extent of fluctuations in
frequency and intensity.
the results showed a significant difference between both the conditions with respect to
speed and extent of frequency and intensity fluctuations, mean, max and min intensity.
There was reduction in the mean intensity and intensity range in post fatigue conditions

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R.M Chitra Tamilmani (2003) did a study on “prevalence of voice problems among
future teachers in banglore”.
Subjects were 307 teachers training students (17-32 yrs) from 5 colleges in banglore.
A questionnaire concerning voice symptoms, a perceptual assessment of voice quality
made by qualified speech language pathologist and a clinical examination by a
laryngologist were carried out.
It was found that 22.2% reported of atleast 1 symptom weekly based on questionnaire,
8.9% had voice problem on perceptual evaluation.
Preciado J, Pérez C, Calzada M, Preciado P (2005) analyzed the risk factors of voice
disorders among teaching staff .
527 teachers of random sample took part in study: 332 female (63%) and 195 male
(37%).
All teachers filled in a standard questionnaire and they underwent an, ENT and
functional vocal cord examination, videolaryngostroboscopy and acoustic analysis with
MDVP.
RESULTS: The prevalence of voice disorders among teachers was 57%
- 20% for organic lesions
- 8% for chronic laryngitis
- 29% for functional disorders.
Women compared with men did not have a higher prevalence of voice disorders
Professional and personal factors as well as classroom atmosphere were studied. The
mostrelevant factors in the pathological group were previous vocal pathology, laryngeal
surgery, gastroesophageal reflux and, classroom dryness and smoking habits.
CONCLUSIONS:
The most relevant factor of voice disorders in teaching professional is the vocal
overwork during their job.
It is advisable that all the teachers should undergo clinical evaluation and follow vocal
hygiene to prevent voice problems

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VOICE PROBLEMS IN ACTORS:
Actors engaged in emotionally changed behaviors or acts in which emotions change
very fast are expected to indulge in screaming, shouting, grooming, grunting and
sobbing, depending on the theme of the play, which are usually considered vocally
violent behaviors.
These behaviors involve extremes in pitch and loudness variation, increase of muscular
tension and explosion of air across the partially closed vocal folds (Ryker, Roy & Bless,
1998).
These leads to vocal abuse and voice disorders. If the acoustics of auditorium is poor,
actors put tremendous pressure on the vocal mechanism and are a source of vocal abuse.
Theatre performance influences the phonatory organ, the laryngeal muscles at first. It is
very difficult to follow changes in the larynx just after a theatre performance.
Brodnitz (1971) has stated that prolonged vocal strain after a theatre performance
exhausts the vocal muscles and causes hypofunction.
Manoj.P (1998) studied the aerodynamic and acoustic features of voice in stage actors
and normals of the age range 20-35 yrs.
Vital capacity, MAFR, MPD, s/z ratio and optimum frequency were measured.
There was no significant difference between the groups ie it was found that stage actors
were not using the speech system differently from the normal group.

VOICE PROBLEMS IN CHEERLEADERS:

High school cheerleaders represent a vocally demanding avocation for adolescent
females.
Cheerleading leaders requires frequent phonation at high SPL. The high SPL requisite
are imposed upon the vocal mechanism which due to laryngeal mutation may be
unstable and vulnerable.
Jensen (1964) reported hoarseness in 12% of 377 cheerleaders.
Andrew and Shanes, 1983 reported 37% of the 102 high school cheerleaders have
history of vocal problems.

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Gillispie and Cooper (1973) the prevalence of both chronic and acute dysphonia among
this population is higher than 0.45% reported for high school girls and directly
proportional to age and no: of yrs of cheerleading experience.
Case, Thome and Kohler (1979) studied high school cheerleaders before and after a
cheerleading camp and found that 44% had vocal pathology during and immediately
after the camp.
There is high prevalence of vocal abuse and injury in this group and the vocal
characteristics include hoarse voice quality, musculo skeletal tension, strained
phonatory patterns, inadequate breath support, increased pitch and loudness levels.
Dysphonia, aphonia, high vertical laryngeal positioning, laryngeal hyperfunction and
increased prevalence of vocal pathologies (Aronson, 1980; Andrew and Shanes, 1983).
Alan, Mc Henry (1986) did a survey of dysphonic episodes among high school
cheerleaders.
Questionnaire responses were obtained from 146 high school cheerleaders.
They reported frequent instances of acute Dysphonia, Dysphonia, pitch breaks,
abnormal voice changes.
Tired voice and sore throat were experienced more frequently during evening following
cheerleading events than in during events no preceding cheerleading.
Shari, Campbell, Reisch (1988) obtained questionnaire responses that encompassed
severity of acute cheerleading related Dysphonia, typical vocal use and vocal history,
smoking, drinking behavior and personality characteristics from 146 high school
cheerleaders.
The results indicated that acute cheer related Dysphonia may be preceded or
accompanied by a compact set of clinical signs that could be easily incorporated into a
screening protocol for prospective cheerleaders.
Case (1991) observed cheerleaders and found:
Cheering without good abdominal breath support
 Cheering with an energy focus in larynx
 Cheering with excessive tension in neck, larynx, using hard and abrupt onset of
voice, cheering at inappropriate levels

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• High school cheerleaders who display acute dysphonic symptoms may be
employing SPL control strategies that are physiologically inefficient. This may result in
chronic structural alterations of the vocal fold tissue and vocal quality deviation.
VOICE PROBLEMS IN ARMY COMMANDERS:
The job of army commanders is to give commands to army (Defence soldiers). They
have to do this for quite a long duration in a day, many days and years under
background noise or open field.
Army commanders are also required to project authority and toughness achieving,
which will put additional pressure on their vocal mechanism.
They have to use loud voice in sharp powerful bursts which many of them achieve using
‘glottal stroke’.
Continuous employment of glottal strokes leads to thickening of vocal fold overtime or
formation of vocal nodules.
Sapir (1993) surveyed the symptoms of vocal attrition in female army instructors, a high
risk group of vocal attrition and in 386 women recruits (low risk).
A questionnaire was used and it was found that high prevalence of symptoms in both
groups and high prevalence among instructors.
There was a significant correlation between no: of symptoms and rapid excessive and
loud speech habits in both the groups and significant correlation between no: of
symptoms and difficulties in performing instructional duties.
VOICE PROBLEMS IN INDUSTRIAL WORKERS:
In industrial set up the need to speak louder and in excessive noisy levels put further
strain on the vocal muscles resulting in tension and vocal abuse.
The fumes, dust, smokes and their mental feelings compound the effect of high noise
level directly on the middle lining of the vocal mechanism and leads to vocal strain.
There is some evidence in the literature to show that female larynx is more susceptible
to vocal cord dysfunction than males from speaking in a noisy environment (Rontal,
Jacob Rotnick, 1979).
Ohlsson, Lofquist (1987) did a study to assess vocal behavior in welders.8 welders and
8 clerks were selected (exposed to noise level of 95 dB at work place).

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A tape recording was made of each subjects reading aloud of a standard test and
sustained phonation of /a/.
These recordings were judged by a panel of 5 trained speech pathologists on an 11 point
scale.
Results revealed that voice and throat problems were more frequent among welders than
for clerks.
The results of the listeners judgement on voice was that welders voice is
hyperfunctional, unstable and clerks voice as hypofunctional stable.
VOICE PROBLEMS IN OTHER PROFESSIONALS:
Jones K, Sigmon J, Hock L, Nelson E, Sullivan M, Ogren F.(2002) investigated whether
there is an increased prevalence of voice problems among telemarketers compared with
the general population and if these voice problems affect productivity and are associated
with the presence of known risk factors for voice problems. 304 employees completed
the survey. 187 community college students similar in age, sex, education level, and
smoking prevalence served as a control group.
Telemarketers were twice as likely to report 1 or more symptoms of vocal attrition
compared with controls
31% reported that their work was affected by an average of 5.0 symptoms.
These respondents tended to be women and were more likely to smoke; take drying
medications; have sinus problems, frequent colds, and dry mouth.
CONCLUSIONS:
• Telemarketers have a higher prevalence of voice problems
• These problems affect productivity and are associated with modifiable risk
factors.
• Evaluation of occupational voice disorders must encompass all of the
determinants of health status, and treatment must focus on modifiable risk factors, not
just the reduction of occupational vocal load.

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 ASSESSMENT
NEED OF ASSESSMENT:
All occupational voice users are dependent on vocal communication in everyday life.
Most people view the loss of voice for even brief time as a major inconvenience. Those
who directly rely on their voices for their livehoods in a public forum are likely to
experience more than an inconvenience with the development of a voice disorders.
Voice disorders, acute or chronic, may threaten, shorten, change or even end some
careers of such people. The impact of vocal disorders in this population is twofold. Not
only does it cause vocal symptoms that are characteristics of the voice disorder, it also
carries with it a high level of emotional strain and anxiety. This anxiety cause by the
disorder’s potential impact on the person’s reputation reduces the ability to meet
professional commitments and performance of the individual’s job. Hence, there is a
need for addressing this group of voice users.
Assessment Team:
A multidisciplinary approach can be followed in the assessment of such population. The
team’s responsibility is to assist the prevention, care and rehabilitation of all types of
voice problems. Each member of the team should have a keen understanding of the
pathophysiology of the individual’s voice disorders. The key members of the voice care
team include,
- Otolaryngologist
- Voice Pathologist
- Primary care physician
The other specialist may include,
- Singing teacher
- Drama coach
- Psychologist
- Psychiatrist
- Neurologist
- Gastroenterologist
- Pulmonologist
- Other medical specialties occasionally
- The composition of voice care team may differ from individual to individual, depending
on patient’s level of vocal usage and demand to return to normal performance.

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 Assessment according to specific types of professions:
It is helpful to understand the pt’s profession. This requires the SLP to explore the
circumstances that might contribute to the voice problem.
SINGERS
• Singers require fine control of the subsystems to produce good aesthetic voice.
• Inefficient and inappropriate compensations developed by the singer have to be noted
during the assessment.
• Assessing the posture, control and flexibility of voice subsystems, their coordination to
produce aesthetic nuances while singing, phonation modes and vocal patterns have to be
assessed.
How are they assessed?
a. Detailed history: This should address and document the singer’s current voice problem,
medical and non-medical problems that the singer thinks might have contributed to the
present condition, singing styles, training details, career goals, vocal and non-vocal
habits, medicines and past medical history etc…
b. Tasks and Recording Protocol: Recording is done using a digital audio tape.
Occasionally a video recording is done in order to give feedback on posture and
mannerisms that influence voice production.
The following samples are recorded to perform singing voice analysis:
1. Phonation
2. Speaking
3. Singing
4. Maneuvers/Singing techniques.
Assessment methods: Sri Ramachandra Protocol (Boominathan, Samuel, Ravikumar &
Nagarajan, 2010)
Aspects or mechanisms of voice production that are affected:
A. Posture and alignment:
The muscle behavior and dynamics of the singer is governed largely by the singing
posture.

B. Breathing: While assessing breathing, document the following:

i. Breathing pattern
ii. Posture
iii. Effort/strain/tension while inhalation/exhalation
iv. Inspiratory gasps/stridor
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 v. Pauses and phrasing while singing
vi. Holding of breath
vii. Excessive abdominal movement/tension
viii. Pulmonary function test: Lung capacities and volumes
ix. Maximum phonation time
x. s/z ratio
C. Phonation: While assessing Phonation, document the following:
i. Phoantion mode
ii. Register transition
iii. Tonic pitch
iv. Fundamental frequency
v. Physiological range
vi. Dynamic range
vii. Quality measures
viii. Rate/tempo control
ix. Characteristics of vocal ornaments
x. Effort/strain/tension while singing
D. Resonance: While assessing aspects of resonance, document tools of tone focus and
nasality.

E. Vocal Ornaments: Ornaments are essential part of superior singing.

Neumann(1970) defines ornamentations as modualtionsof the basic structure of a
musical piece that emobodies all the elements of the artwork that are essential to its
meaning and purpose.
It is important to understand the physiology and acoustics behind such vocal skill to
develop training methods and achieve mastery of the same.

ACTORS
Interview/case history:
Performing voice professionals have unique needs, which require additional
history and examination. Following questions can be added to the proforma to get
adequate info about the nature of the professional work.
Examination of neck and larynx:
Speech pathologist should do palpitation before the instrumental evaluation from
ENT specialists. One can palpate the larynx and neck with phonation and dialogue for
excessive tension, freedom during speaking, pitch glides, tenderness and symmetry of
hyoid bone.
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1. Demonstrates the base of the tongue palpation that elicits excessive tension with
phonation
2. Palpation of Thyrohyoid membrane and freedom during speaking/singing
3. Palpation of the Cricothyroid membrane during pitch glides
4. Palpation of the hyoid horn for tenderness and symmetry
5. Palpation of the superior thyroid cornu for the tenderness and motion
Functional evaluation:
1. Visual examination of the soft palate and pharnynx
2. Aerodynamic exploration
3. Articulation examination
Perceptual evaluation:
Perceptual evaluation of the vocal performer should be beyond GRBAS (Hirano,
1981). Perceptual assessment of actors voice need more formalized scheme. (Oates et.al
2006) has developed auditory perceptual rating scale for singing voice.
Instrumental evaluation:
Test protocol which can be followed is given below ( Woo,2008)
1. Laryngeal anatomy and mucosal health
2. Laryngeal movement, vegetative, non voicing gestures
3. Voice testing
The videostrobolaryngoscopy (VSL) permits detection of vibratory asymmetries,
structural abnormalities, small masses, sub mucosal scars and other conditions that are
invisible under normal light.(Sataloff 1991) Evaluaton includes the symmetry of
movements, fundamental frequency periodicity , glottis closure , the amplitude, the
mucosal wave, the presence of nonvibrating portions of vocal fold.
Electroglottography (EGG) has been studied very little in professional voice users,
none in actors specifically in Indian context.
Acoustic analysis and Spectrograhic Analysis:
Among the several possibilities of the acoustical analyses, the long term average
spectrum(LTAS) has been used most widely because it allows quantifying the quality of
voice, making differences of gender, age professional voices, making the differences of
gender, age, professional and dysphonic voices, contributing not only to the evaluation
but also to follow up training or treatment.

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 TEACHERS
The teaching voice can be assessed based on two dimensions/aspects:
1. Self reported vocal difficulties
2. Vocal dose measures

1) A detailed case history followed by self reported voice problems of teachers may be
collected through certain questionnaires.
Rantala, Vilkman and Bloign(2002) used a questionnaire to document the subjective
voice complaints. The symptoms enquired are fatigue after loading, non-infectious
dysphonia/hoarseness of voice, feeling of lump or mucous in the throat, pain in the
throat, lack of voice endurance, lack of vocal penetration in noise, voice breaks,
complete loss of voice/aphonia and sick leaves due to voice problems. The
questionnaire used 4-point rating scale where 1 indicates presence of symptom less than
once a year, 2 indicates seldom, 3 indicates once a month or relatively often and 4
indicates almost every week or more often. If the scores exceed 17, the given teacher is
at risk to develop voice disorder .

2) Vocal dose measures: Generally the ‘environmental noise’ is measured/quantified by

‘Dose’. Titze et.al(2003) reported 3 doses in voice quantification. They are:
a. Time dose: it is equal to the voicing time and emsures the total time the vocal folds are
vibrating. It is the simplest vocal dose, often called the voicing time, which accumulates
the total time the vocal folds vibrate during speech.
b. Cycle dose: measures the total number of cycles accomplished by the vocal folds(in the
unit of thousands).
c. Distance dose: measures the total distance travelled by the vocal folds on their
oscillatory trajectory.
Instruments for measuring vocal doses:
Two methods are available. First is the automatic method which uses micro-
processors for recording and analyzing the samples. Second is the manual method
where the extraction of voicing periods and others are done manually using available
software.
a. Voice dosimeter ( Titze et. al 2003,2005): device to extract and store F0 from the
wearers voice signal. A pocket PC is adapted for the same purpose. It quantifies all the 3
doses.

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 b. Ambulatory phonation monitor (APM): is a portable device worn by a client in order t
extract important parameters of vocal behavior over an entire day of normal activities.
c. Manual method: the voicing periods or percentages can be measured with the help of
digital voice recorder and PRAAT software. The continuous long speech samples can
be recorded using a recorder and the voicing periods can be extracted from the pitch
curve of PRAAT software.
The analysis of teaching voice can be carried out in any of the 2 conditions”
i. Laboratory condition: most of the vocal loading studies are done in lab condition i.e.
simulation studies where generalization of the results to the natural condition is the
main drawbacks behind these studies. Under lab conditions, one of the benefits is that,
other intervening variables are under control.
ii. Field condition: the samples of analysis of teaching voice are recorded/acquired from
the school/ classroom situation where the background noise may be present.
GENERAL ASSESSMENT
A) Detailed case history
B) Physical examination
C) Subjective evaluation
D) Objective evaluation
A) Detailed Case History:
Age: As the vocal mechanism undergoes normal maturation, the voice changes.
• The optimum time to begin serious vocal training is controversial.
• Vocal training and serious singing near puberty in female and after puberty in
males is generally recommended (Sataloff, 1981).
• The voice also changes due to normal aging.
• Generally the voice becomes breathy and the vocal range reduces.
• This is because abdominal, thorax and general muscle tone and elasticity
decreases.
• Aging effect is more pronounced in female than in males.
• Excellent male’s singers may extend their voice to more than 70 years while it is
usually 50 years for females.
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Complaint: It is important to identify acute and chronic problems before beginning
therapy to have realistic expectation and optimum therapeutic section.
• Hoarseness – coarse or scratchy sound often associated with laryngitis or mass
lesion.
• Breathiness – vocal quality characterized by excessive loss of air during
vocalization after associated with vocal cord paralysis, mass lesions.
• Fatigue – Inability to continue to sing for extended periods. The voice may
become hoarse and change timbre. Misuse of abdominal muscle, neck muscle overuse,
singing too loud, too long cause fatigue.
• Volume disturbance – Inability to sing loudly or inability to sing softly.
• Warm up time – Most singer require about 10 min to half an hour of warm up
time.
• Pain – Infection or gastric acid irritation of arytenoids vocal abuse.
Date of next important performance:
An important consideration in management caring for voice complaints in these
situations require highly skilled judgement
Professional singing status and goals:
A singer’s voice is his / her most important commodity. Canceling the concert may
hamper the singer’s concrete plans as well as can be ill-advised performance.
Amount and nature of vocal training:
• Extensive voice use without training or premature training with inappropriate
repertoire may underlie persistent vocal difficulty later in life.
• No. of years of training is an important factor (more experienced better vocal
proficiency).
• A vocal student must not change voice teacher frequently as methods vary among
voice teachers.
Types of singing and environment:
• Lombard effect – Tendency to increase vocal intensity in response to increased
background noise.

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• A well trained singer (classical music singer) learns to compensate for this
tendency; however singer performing in large hall orchestra tends to over sing and
strains their voices e.g. pop-singers.
Rehearsal:
• Physician should know how long he / she practices; at what time.
• Serious practice for one or two hour / day is usually recommended.
• A laryngologist / SLP should also be certain that professional voice users ‘warm-
down’ the voice.
Vocal abuse in singing:
• The most common technical error involve excessive muscle tension in the tongue,
neck and larynx.
• These may be due to inadequate preparation or limited vocal training or both
voice abuse is more common in pop-singers.
General health:
• The vocal mechanism is finely tuned, complex instrument and is exquisitely
sensitive to minor changes.
• Substantial fluctuations in weight frequently result in deleterious alterations of
the voice, although these are usually temporary.
• A history of sudden recent weight change may be responsible for almost any
vocal complaint. Infections sinusitis may alter the sound of a singer’s voice.
• Reflux laryngitis is common among singers because of the high intra-abdominal
pressure associated with proper support.
Exposure to irritants:
Allergies to dust are aggravated commonly during rehearsals and performance in older
concert halls because of the numerous curtains, backstage trappings and dressing room
facilities that are rarely cleaned thoroughly.
The drying effects of cold air and dry heat may also affect mucosal secretions, leading
to decreased lubrication and a scratchy voice and tickling cough.
Singers must be careful to avoid talking loudly and to maintain nasal breathing and
good hydration during air travel.
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Smoke:
Stage smoke present a special problem, commonly encountered by actors.
This smoke may be especially irritating and dangerous, especially if it’s oil-based.
Smoking should not be permitted in serious singers because tobacco smoke and heat
causes mild edema and generalized inflammation through out the vocal tract.
Drugs:
Singers should take all drugs very carefully as many have side effects and may alter the
voice.
Few drugs like antihistamines, antibiotics and diuretics which are popularly used by
singers should be taken with caution.
Cocaine use is increasingly common, especially among pop musicians. It can be
extremely irritating to the nasal mucosa, causes marked vasoconstriction resulting in
decreased voice control land a tendency toward vocal abuse.
Foods:
Various foods are said to affect voice. Traditionally milk and ice-cream are avoided by
singers before performances.
Coffee and other beverages containing caffeine also aggravate gastric reflux and seem
to alter secretions and necessitate frequent throat clearing in some people.
Lemon juice and herbal teas are both felt to be beneficial to the voice.
Surgery:
Any history of surgery involving thoracic, abdominal laryngeal, supralaryngeal
structures is a matter of great concern.
Surgical traumas may also cause vocal dysfunction. Tonsillectomy cause vocal
dysfunction. It takes three to six months for a singer’s voice to stabilize to normal
voice.
Thoracic and abdominal surgery interferes with respiratory and abdominal support.
B) Physical examination:
1. Musculoskeletal and postural issues
Primary musculoskeletal causes for dysphonia
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• Age related classification of the laryngeal costal cartilages
• Muscular spasm
• Poor posture
• A prolapsed cervical disc
Secondary musculoskeletal issues:
• A high held larynx with tight suprahyoid musculature in patient with emotional
stress.
• Supraglottic hyper function and laryngeal guarding may be evident in patient with
gastro esophageal reflux, vocal fold palsy, bowing and sulcus vocalis.
• Limitation or restriction of movement of neck, laryngeal cartilages and
cricothyroid joint have direct impact on performance and should be examined.
• Previous neck surgery could cause scar bands limiting laryngeal motion and thus
have an impact upon the voice (Sataloff, 1991).
2. General ENT Examination
The ears, nose and throat should be examined routinely by an otorhinolaryngologist.
Some type of permanent, laryngeal recording should be made like stroboscopy
(Sataloff 2003). It helps the performer in education, assurance and involvement during
therapy.
C) Subjective evaluation:
Many vocal problems are the result of improper breathing technique.
When evaluating respiration, the volume of air is important, but more critical is the
manner in which the patient takes in air (inhalation) and how the air is used to produce
the voice (exhalation).
Abdominal / diaphragmatic breath control and support are desirable and are the most
efficient manner of providing the power source of the voice.
The patient’s respiration is observed in conversation speech and in reading.

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I. Respiration:
The following observation are made:
 The pattern of breath support
• Abdominal / diaphragmatic
• Upper thoracic
• Clavicular
• Combined or mixed (thoracic and abdominal)
 Posture
• Head / neck malalignment
• Improper sitting posture
• Improper standing posture
 Phrasing
• Too many words per breath
• Too few words per breath
• Failure to take appropriate pauses
• Excessive pauses
 Respiration
• audible respiration
• forced exhalation
• labored breathing
II. Phonation:
• Judgements about the voice quality (hoarseness, breathiness), loudness
(appropriate, too loud, too soft) and pitch are made during conversation speech and
reading.
• The following characteristics are particularly important:

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o Hoarseness
o Breathiness
o Glottal fry
o Diplophonia
o Phonation breaks
• Measures of respiratory and phonatory efficiency are obtained using
measurement of maximum exhalation or phonation for the following sounds /a/, /i/, /u/,
/s/, & /z/.
• S/Z ratio provides useful information about the patients ability to control
exhalation in the presence or absence of voicing i.e. it is an indicator of laryngeal
efficiency.
• General observations are made regarding the patients habitual speaking pitch like
appropriate pitch level, too high or too low.
III. Resonance:
Excessive pharyngeal or ‘throaty’ resonance is a common characteristics and can be
associated with physical discomfort in speaking.
Oral resonance is desirable and is affected by the size and shape of the oral cavity.
Many patients exhibit mandibular restrictions while speaking which diminishes the
effectiveness of the oral cavity as a resonator.
The presence of hyper or hypo nasality should be assessed carefully to rule out
velopharyngeal inadequacy.
IV. Articulation:
The ability of the articulators (tongue, lips, teeth, jaw & velum) to function in a smooth
and connected manner in determined.
Although articulation disorder is rare in this population, occasionally a ‘lisp’ has been
identified.
V. Prosody:
The prosodic features of speech (rhythm, fluency, timing rate, pauses and intonation or
inflection patterns are assessed generally.

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 D) Objective Evaluation: .
Measures of vocal function include:
• Assessment of vibratory function
• Aerodynamic measures
• Acoustic analysis
• Laryngeal electromyography
i. Assessment of vibration:
Strobovideo laryngoscopy to assess Glottic appearance & configuration, supraglottic
activity, appearance vibratory motion, mucosal wave, amplitude, periodicity etc
ii. Aerodynamic measures:
Parameters assessed
• Vital capacity
• Mean airflow rate
• Sub glottal pressure
• Glottal resistance
iii. Acoustic analysis:
It provides concrete information
• Fundamental frequency
• Jitter
• Frequency range
• Intensity
• Shimmer
• Dynamic range
• Signal to noise ratio
iv. Laryngeal electromyography

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STEPS TO AVOID VOICE DISORDERS IN PROFESSIONAL VOICE USERS
Vocal hygiene is the term used for the use and care of the human voice required to keep
it healthy.
Individuals who put extra strain on their voices must keep their vocal mechanism in
better condition. This can be especially true if an injury has occurred, even if the
individual previously had no extraordinary voice needs.
Consult an Ear, Nose, and Throat Doctor (ENT): Consult an otolaryngologist, or
ENT, to obtain a baseline evaluation of the voice when healthy.
Establishing a healthy picture of the larynx serves as a source of comparison if
encounter voice difficulties in the future.
Maintain adequate hydration:
Many physicians and clinicians propose that consuming approximately 64 ounces of
non-alcoholic fluids per day is necessary to maintain adequate hydration.
Research supports that adequate hydration allows vocal cords to vibrate with less
“push” from the lungs, especially at high pitches
In addition, well-hydrated vocal cords resist injury from voice use more than dry cords,
and recover better from existing injury than dry cords.
Increased systemic hydration also has the benefit of thinning thick secretions. (Titze,
1988; Verdolini-Marston, Druker, & Titze, 1990; Verdolini, Titze, & Fennell, 1994;
Verdolini et al., 2002; Titze, 1981; Verdolini-Marston, Sandage, and Titze, 1994).
Individuals who experience external dehydration, such as those individuals living or
working in a very dry environment, may benefit from the use of a humidifier or
vaporizer.
Always warm-up and cool-down.
Warming-up the voice is important before prolonged speaking or any singing
engagements.
A simple, yet effective vocal warm-up is to perform lip-trills while gliding up and down
the full extent of one's pitch range.
Although frequently ignored, vocal cool-downs may also be used to prevent damage to
the vocal cords.

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The simple practice of gentle and relaxed humming can serve as one excellent, easy
form of cooling-down.
Practice good breathing techniques when singing or talking.
It is important to support voice with deep breaths from the diaphragm, the wall that
separates your chest and abdomen.
Singers and speakers are often taught exercises that improve this breath control.
Talking from the throat, without supporting breath, puts a great strain on the voice.
Know the potential side effects of medications.
Many commonly prescribed medications can have significant effects on the voice.
Screen daily for vocal cord swelling.
Screening for potential vocal cord swelling will help to determine whether they should
perform on a particular day, or take a vocal rest.
When singing with a band, use monitors.
Have some small speakers facing on stage so they can hear themself adequately and
modify the volume accordingly.
Avoid vocally abusive behaviors.
In every day communication, be sure to avoid habitual yelling, screaming, or cheering.
Try not to talk loudly in locations with significant background noise or noisy
environments.
Be aware of background noise—when it becomes noisy, significant increases in voice
volume occur naturally, causing harm to voice.
If throat is dry, tired, or voice is becoming hoarse, stop talking.
To reduce or minimize voice abuse or misuse use non-vocal or visual cues to attract
attention, especially with children.
Obtain a vocal amplification system if routinely need to use a “loud” voice especially in
an outdoor setting.
Try not to speak in an unnatural pitch.

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Adopting an extremely low pitch or high pitch can cause an injury to the vocal cords
with subsequent hoarseness and a variety of problems.
Minimize throat clearing:
Clearing throat can be compared to slapping or slamming the vocal cords together.
Consequently, excessive throat clearing can cause vocal cord injury and subsequent
hoarseness.
An alternative to voice clearing is taking a small sip of water or simply swallowing to
clear the secretions from the throat and alleviate the need for throat clearing or
coughing.
The most common reason for excessive throat clearing is an unrecognized medical
condition causing one to clear their throat too much.
Common causes of chronic throat clearing include gastroesophageal reflux,
laryngopharyngeal reflux disease, sinus and/or allergic disease.
Avoid behaviors that may exacerbate acid reflux.
Certain behaviors and foods may exacerbate acid reflux and yield poor vocal
performance.
Avoid eating spicy foods. Spicy foods can cause stomach acid to move into the throat or
esophagus (reflux).
Avoid smoking:
It is well known that smoking leads to lung or throat cancer.
Primary and secondhand smoke that is breathed in passes by the vocal cords causing
significant irritation and swelling of the vocal cords. This will permanently change
voice quality, nature, and capabilities.
Limit intake of drinks that include alcohol or caffeine.
These act as diuretics (substances that increase urination) and cause the body to lose
water.
This loss of fluids dries out the voice.

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