VOICE DISORDERS |
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People who have use of their voices constantly, especially at work, may be at risk for developing voice disorders. Chief among these are lawyers, marketing professionals, and teachers! The following is adapted from an article which appeared in "California Worker's Compensation Enquirer" (1997). TEACHERS AND VOICE DISORDERS - WHAT CAN BE DONE?"Argguh!" she holds her neck and throat in both hands as she painfully tells me how her voice feels after that 5th period class. As she speaks, the hoarse, raspy, strained voice is even more prominent than her agonized description. "It's getting now so that by the end of the 1st period I feel the hoarseness. By noon, my voice is breaking and then about the end of the 5th period there's nothing left. It hurts! I try harder and even less comes out. Some of my students seem concerned , but most of them begin to take advantage of my awful voice. Discipline has never been more of a problem then it it is now, and I think my voice has a lot to do with it.." Barbara is a 35 year old middle-school English teacher. She had begun to experience recurrent hoarseness about a year before; her 7th year as as a teacher. She was referred to a laryngologist toward the end of that school year. He found that her vocal cords were red and somewhat swollen and advised voice rest. " I thought he must be kidding," Barbara remarks ruefully, " How can a teacher get voice rest? then I realized that final exams were just a couple of weeks away, and this was going to be the summer when I was going to 'do nothing'. I was planing to read, prepare new lesson plans for the next semester, vacation with my husband and not too much else." Barbara found that through final exams, her voice continued to worsen. By the end of the school year, she was almost 100% hoarse and had begun to experience voice breaks- the sudden absence of voice on parts of words or sometimes the whole word. The hoarseness, pitch breaks and soon after, pain upon talking that Barbara experienced, are all indicators of extreme vocal fatigue, one of the elements that occurs in hyperfunctional dysphonia a term which relates to excessive effort, overuse and under response of the speaking voice. More and more effort goes into speaking and less and less quality emerges. Though Barbara did experience some vocal improvement during her "do nothing " summer, by the end of the third week of the fall semester, her voice problem had not only returned but had increased in severity. It was then that she was seen in my office, describing what the voice was like at the start, and then at the end of a school day. But by this time, the temporary relief she used to experience from " no talking" weekends no longer occurred. Even if she didn't speak at all in the evening after a teaching day, the voice was hoarse upon first use in the morning. Barbara's return to her laryngologist, shortly before our first session, also showed the beginning of vocal nodules- tiny bumps on each vocal cord, opposing one another, which can become larger and interfere increasingly with normal voicing if they are not treated. Her physician explained that surgery was a possible option, but that even when vocal nodules are removed surgically, the areas along the vocal cords where they had developed can be weaker and give rise to more vocal nodules, unless vocal habits and voice use change. The laryngologist recommended that Barbara first try voice therapy, before considering surgery, and that is how she came to my office. Voice disorders occur with alarming frequency among school teachers. The exact incidence is unknown, but it is an occupational hazard of considerable importance. It is not hard to understand why teachers as an occupational group are prone to the development of voice disorders. Their most important teaching tool is the voice. Vocal use often occurs in less than ideal circumstances with poor acoustics, noisy students and a tense atmosphere. Large classes and discipline problems add to the teacher's vocal demands. Sometimes the initial occurrence of hoarseness is combined with an upper respiratory infection which has caused a great deal of coughing or throat clearing. But more often, years of teaching and not using the best breath support or vocal modulation has lead to gradual breakdown in the delicately balanced mechanism of the voice. The first response of most teachers who begin to experience recurrent hoarseness is frustration bordering on panic. "I can't be losing my voice" becomes "I won't lose my voice!" and changed, maladaptive habits of voicing begin to develop with increased hoarseness, pain , pitch breaks, fatigue and vocal nodules as the result. While these nodules are normally not cancer, patients become extremely concerned. In some ways this concern helps patients make the decision to obtain medical and voice assistance more quickly, which in turn helps them obtain the reassurance that through the problem may be serious and need treatment, it is not cancer. In other instances, the concern simply adds to aggravation, anxiety and worry. After Barbara finished sharing her history, her voice was evaluated. Each component of the voice - pitch, loudness vocal variety, vocal clarity, resonance factors, breath support and amount and sources of pain were observed and analyzed. It was determined that, as she was attempting to forestall the effects of the hoarseness, Barbara had unknowing lowered her pitch and constricted her laryngeal muscles, to try to maintain the loudness level of her voice. Further, Barbara's voice quality was now "throaty", meaning that resonance tended to reside deep in the throat rather then in the "mask," (the mouth and nasal area) adding to her effort to have her voice heard clearly. Barbara's ability to project her voice was also severely impaired by poorly utilized breath support. Limitations in breath support can stem from childhood, for a variety of reasons, and lead to the degradation of the voice over the years; or can be secondary to vocal efforts imposed by the need to sustain vocal projection. Regardless of the cause, Barbara's breath support problem was pertinent to the rehabilitative plan for her voice. Following the voice evaluation, Barbara described and demonstrated her teaching style and the nature of her classroom. These personal and environmental factors are important in determining the components of rehabilitative voice therapy, and what reasonable expectations we can have for success. Finally, and fortunately, Barbara did not smoke, was not exposed to cigarette smoke at home, and did not experience any interpersonal or environmental factors in the home which would cause or reinforce vocal dysfunction. These factors are positive determiners of prognosis. However,Barbara's dedication to her classes, the recurring need for disciplining of certain students, the size of the classroom and noise factors associated with it, the way she presented her instructional content, and the lack of an aide, were negative factors that might indicate a poorer prognosis. At the very least, they indicated the need for serious consideration of changes in the classroom and teaching style, including the possibility of using amplification to reduce vocal effort. The information obtained in Barbara's history, together with the results of the evaluation, and my assessment of Barbara's motivation for her vocal change, contributed to the development of a treatment plan for her. My report and recommendations about the treatment plan were sent to Barbara's referring physician and Work Comp carrier. I began plans for treating her voice disorder. Barbara proved to be an excellent patient. She took suggestions seriously, did the home program exercises as instructed, restructured some of her teaching tasks so that her better students could assist in instruction, asked for and was provided with a portable amplifier and a part-time temporary aide, and achieved additional improvement in classroom decorum by explaining her problem to her students. She was surprised at the concern expressed by many of these students, who wanted to make sure that she was able to continue teaching them. Barbara said, " Indirectly, I found out how important I was in the lives of those students, and I am really grateful for their response to my problem." Within two months of treatment, Barbara's vocal nodules had reduced in size to a considerable extent. Within four months of treatment, they had disappeared. By the end of six months, Barbara's voice had largely restored and she was able to use it functionally to a greater extent throughout her teaching day. She discontinued using her amplifier, feeling it was an artificial barrier to contact with her students. But it had helped. She still tended to experience some vocal fatigue, especially if she read to her class. This oral reading was the most difficult element in Barbara's teaching style to give up. She "loved" reading to her students and she did it with a dramatic flair. It is interesting that Barbara developed the insight during the course of therapy, that a frustrated career as an actress, much earlier in her life, was in part relieved by these oral readings to her class, in which she would take on all the roles in the story from the high-pitched screech of a delighted baby, to the low- pitched growl of an angry man. During the course of voice therapy, Barbara began to realize how these "special voices" - which she felt were so important to her teaching style - were aggravating her already abused voice. She also found that her students were willing, even eager, to take on some of these roles by acting a portion of each story, or by sharing the responsibility of reading the stories to the rest of the class. At the conclusion of the semester, Barbara's voice was essentially within normal limits. She had not lost any appreciable teaching time during the course of voice therapy, yet she had experienced considerable benefit. Barbara was a major factor in her own voice improvement. She was a positive and responsive patient; she attended not only to her own voice, but to issues within the classroom and found creative solutions to many problems. Unfortunately, this course and outcome are not always true of voice patients. In some cases, it is necessary for patients to discontinue teaching during the early stages of voice therapy to allow some natural healing to occur. This in turn helps to insure the voice therapy will have a reasonable chance of achieving success. In other instances, treatment must extent for a longer period of time and amplification may be a necessary component to teaching, even after treatment has ended. Barbara was also fortunate that gastric esophogeal reflux disease, (GERD) was not contributing to her vocal disorder. In voice patients with GERD, treatment may be longer and also involve close medical supervision. Teachers are a vital force in American society. We have enormous need for more and better teachers. Unfortunately, teachers also are susceptible to serious problems affecting their most precious tool, the speaking voice. Prompt and proper voice evaluation and therapy can often eliminate the need for laryngeal surgery and can do much to restore a teacher to full effectiveness within the classroom.
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