gms | German Medical Science

100 Jahre Phoniatrie in Deutschland
22. Wissenschaftliche Jahrestagung der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie
24. Kongress der Union Europäischer Phoniater

Deutsche Gesellschaft für Phoniatrie und Pädaudiologie e. V.

16. bis 18.09.2005, Berlin

Management of teachers' voice disorders with vocal training and psychotherapeutic sessions

Stimmrehabilitation und Psychotherapie – Anwendung bei Lehrern


100 Jahre Phoniatrie in Deutschland. 22. Jahrestagung der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie, 24. Kongress der Union der Europäischen Phoniater. Berlin, 16.-18.09.2005. Düsseldorf, Köln: German Medical Science; 2005. Doc05dgppP12

The electronic version of this article is the complete one and can be found online at:

Published: September 15, 2005

© 2005 Niebudek-Bogusz et al.
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Voice disorders in teachers are not only a serious medical but also social and economic problem in Poland. It has been shown that teachers are at risk of developing occupational dysphonia which account for over 25% of all occupational diseases diagnosed in Poland. Voice problems affects psychological wellbeing of teachers, while psychological factors may induce escalation of voice pathologies in this professional group.

The study was aimed to assess the effectiveness of phoniatric treatment including voice therapy and psychotherapy in female teachers with chronic dysphonia. The study group included 45 subjects with voice disorders, including hyperfunctional dysphonia, glottal incompetence and vocal nodules. Twenty one teachers of that group additionally underwent short forms of psychotherapy. Questionnaire surveys, phoniatric examination and videostroboscopic evaluation were performed before and after voice therapy.

A significant improvement in the majority of voice problems, and objectively assessed symptoms and voice parameters was achieved in the study group, particularly in teachers treated by voice therapy associated with psychotherapy, as compared to the controls. After the treatment, the number of the patients with voice disorders, particularly with hyperfunctional dysphonia, decreased.

In conclusion, the complex phoniatric treatment including vocal training and short forms of psychotherapy seemed to be an effective method of therapy for patients with occupational dysphonia.

Keywords: teachers, occupational dysphonia, vocal training, psychotherapy



Recent studies have indicated that teachers are more likely to develop voice disorders [1]. According to large-scale US estimations, over 58% of teachers complain of occupational voice disorders, and 18% of them have to take at least one day off work within a year due to voice problems [2]. In Polish studies, 69% female teachers vs. 36% non-teachers reported lifetime voice problems. The clinical studies, including phoniatric examinations and videostroboscopy, revealed symptoms of occupational dysphonia in about 32.7% subjects (vs. 9.6 % in the control group) [3]. In recent years, voice disorders in teachers have made up over 25% of all occupational diseases diagnosed in Poland.

Prolonged voice effort, often in the presence of background noise, has been postulated as a risk factor for vocal disturbances in this profession. Voice diseases affect psychological wellbeing of the patient, which in turn exacerbates the voice pathology [4]. These psychosomatic stressors may contribute to professional burnout, frequently noted in teachers. Weber reports that psychic and psychosomatic complaints made up 41% of all diseases diagnosed in early pensioning German teachers [5]. A psychosomatic condition frequently reported in teachers is hyperfunctional dysphonia (often coupled with glottal incompetence), which may lead to organic diseases of the larynx (e.g. vocal nodules, polypoid hypertrophy). However, not only the psychological factors but also the lack of basic knowledge of vocal hygiene and the principles of correct voice emission contribute to the high prevalence of occupational dysphonia in teachers.

The aim of this paper was to assess the effectiveness of voice therapy combined with short forms of psychotherapy among teachers with voice disorders.

Subjects and methods

The subjects were 85 female teachers with chronic dysphonia. The mean age of the study population was 38 years and average employment duration 14 years. The subjects were assigned to three groups: group I (n=40), with no vocal training - control group; group II (n=24) receiving vocal training; group III (n=21) receiving both vocal training and psychotherapy. In addition, all the groups were briefed about voice hygiene (indirect therapy). All the subjects responded to a questionnaire and had phoniatric examinations, including videostroboscopy, before and after therapy. The vocal training program was conducted by two logopedists and consisted of three phases: (1) deep diaphragmatic breathing exercises; (2) resonator activation, phonation and articulation exercises; and (3) feedback exercises to check assimilation of the newly-acquired vocal behaviour in spontaneous speaking. Vocal therapy was adjusted to the patient's need and comprised on average 12 one-hour exercises performed approx. over a three months' period. The psychotherapy program consisted of six one-hour sessions and included neuromuscular relaxation intended to relieve the patient's stress as well as reduce tension in the pharyngeal and laryngeal muscle areas.

To assess the effectiveness of the therapy, the subjective symptoms reported by the patients and the analysis of voice parameters by a phoniatrist were considered. Fisher exact test was used to compare the results of the vocal training program in preliminary and final examination. For comparing the quantitative parameters a multi-way analysis of variance was applied.


Teachers aged 45-55 years (44%) constituted the largest group seeking phoniatric advice for voice disorders. However, young teachers up to 35 years of age made up as much as 34% of the subjects. The most frequently diagnosed conditions were hyperfunctional dysphonia (88% patients) and glottal incompetence (80%). Vocal nodules were detected in ca. 15% of subjects. The results confirmed that voice therapy was effective for subjective improvement in voice quality in most of the teachers who received vocal training (80%). This finding referred to 14% controls, treated by indirect therapy only (vocal hygiene education). A more noticeable improvement regarding videostroboscopic parameters was found in group III who had received a combination of vocal and psychological training, as compared to group II with vocal training only. The least effective method was the indirect therapy (group I). As regards videostroboscopic findings, vocal fold closure improved significantly in 65% of subjects in group III and 38% in group II (Figure 1 [Fig. 1]). The maximum phonation time (MPT) increased by ca. 3 seconds after the direct therapy (vocal training and/or psychotherapy), while in the subjects receiving only the indirect therapy (group I) this aerodynamic parameter did not change (Figure 2 [Fig. 2]). MPT improved significantly in 86% of subjects undergoing a combined therapy (vs. 50% of subjects with vocal training only). Our analysis of the effectiveness of phoniatric treatment in the total study population showed a recession of hyperfunctional dysphonia symptoms in as much as 83% of subjects, of glottal incompetence in 36%, and of vocal nodules in 10.6% of subjects.


The present study confirmed the hypothesis that vocal training could contribute to improving voice efficiency in people whose jobs involve considerable vocal effort. However, some authors report a low ratio of spontaneous improvement in occupational dysphonia among teachers [3], [6]. Our study was focused on the application of direct voice treatment (vocal training) in combination (when required) with stress-reduction techniques to manage voice disorders in this occupational group. The ability to cope with work-related burnout is an essential part of the voice therapy, particularly in the subjects with psychological background of dysphonia [7].

The occupational voice disorders in teachers may be prevented by regular phoniatric examinations during their professional career. A comprehensive management of voice disorders by phoniatrists in cooperation with logopedists and psychologists seems to be an effective method for the treatment of teacher's dysphonia. This is essential when we consider that the patients with voice disorders related to excessive vocal effort constitute the largest group diagnosed with occupational diseases in Poland.


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