Self-reported Voice Research Articles

Digital voice analysis as a biomarker of acromegaly.

There is a considerable diagnostic delay in acromegaly contributing to increased morbidity. Voice changes due to orofacial and laryngeal changes are common in acromegaly. Our aim was to explore the use of digital voice analysis as a biomarker for acromegaly using broad acoustic analysis and machine learning. Voice recordings from patients with acromegaly and matched controls were collected using a mobile phone at Swedish university hospitals. Anthropometric and clinical data and the Voice Handicap Index (VHI) were assessed. Digital voice analysis of a sustained and stable vowel [a] resulted in 3274 parameters, which were used for training of machine learning models classifying the speaker as "acromegaly" or "control". The machine learning model was trained with 76% of the data and the remaining 24% was used to assess its performance. For comparison, voice recordings of 50 pairs of participants were assessed by 12 experienced endocrinologists. We included 151 Swedish patients with acromegaly (13% biochemically active and 10% newly diagnosed) and 139 matched controls. The machine learning model identified patients with acromegaly more accurately [area under the receiver operating curve (ROC AUC) 0.84] than experienced endocrinologists (ROC AUC 0.69). Self-reported voice problems were more pronounced in patients with acromegaly than matched controls (median VHI 6 vs 2, P < .01) with higher prevalence of clinically significant voice handicap (VHI ≥20: 22.5% vs 3.6%). Digital voice analysis can identify patients with acromegaly from short voice recordings with high accuracy. Patients with acromegaly experience more voice disorders than matched controls.

Prevalence of Voice Problems and Associated Risk Factors in Islamic Religious Orators

Islamic leadership is a diverse profession and previous research has highlighted the increased risk of voice problems among Islamic leaders. The prevalence and risk factors for voice problems among Malayalam-speaking Islamic religious orators have not been adequately investigated. This study aimed to assess the prevalence of self-reported voice problems among Islamic religious orators who recite the Adhaan and those who do not and to examine the impact of age and associated risk factors. This study employed a non-experimental research design using survey research. The current findings report a high prevalence of voice problems among Islamic Adhaan reciters and suggest that age-related differences may influence the risk factors associated with voice problems in this population. Only two participants from the older group of Adhaan reciters had received voice therapy, suggesting that the majority of Islamic religious reciters lack knowledge about voice care and voice therapy. A limitation of the study is the lack of otorhinolaryngological examination, particularly laryngoscopy and voice analysis of Islamic religious orators. Further studies can investigate the effect of vocal hygiene training or similar voice management programs on Islamic religious orators' voices.

Prevalence of self-reported voice and swallowing complaints in an outpatient geriatric population.

Older adults suffer from increased rates of dysphagia and dysphonia, both of which have a profound effect on quality of life and are often underdiagnosed. We sought to better understand the prevalence of these complaints and the potential utility of a patient-reported screening program in a geriatrics clinic. Using an IRB-approved cross-sectional survey and retrospective cohort design, we recruited participants from a population of new patients seeking care at an academic geriatrics clinic. We used three validated questionnaires to assess self-reported dysphagia, dysphonia, and pill dysphagia: the Eating-Assessment Tool-10 (EAT-10), the Voice Handicap Index-10 (VHI-10), and the PILL-5. Patients who screened positive on any questionnaire were offered referral to a laryngologist for additional evaluation. Patients who screened positive on the PILL-5 were also offered referral to our geriatric pharmacist. Among our 300 patients surveyed, the mean age was 76 (SD 8.46). A total of 82 (27.3%) patients screened positive (73 on EAT-10, 10 on PILL-5, 13 on VHI-10) and were offered referral, of which 36 accepted. These positive screening patients took more prescription medications (p = .024) and had a higher GDS score (p < .001) when compared to the patients who screened negative. Many new patients seeking generalized care at our center screened positively for dysphagia and/or dysphonia on validated questionnaires. Geriatric patients may benefit from integrating screening for these disorders to identify the need of further evaluation. It is unknown if these survey tools are appropriate in a non-otolaryngology clinic. III.

Lee Silverman voice treatment versus NHS speech and language therapy versus control for dysarthria in people with Parkinson’s disease (PD COMM): pragmatic, UK based, multicentre, three arm, parallel group, unblinded, randomised controlled trial

ObjectivesTo assess the clinical effectiveness of two speech and language therapy approaches versus no speech and language therapy for dysarthria in people with Parkinson’s disease.DesignPragmatic, UK based, multicentre, three arm,...

Voice Disorders and Hearing Loss May Be Additive Risk Factors for Depression in a National Cohort.

Hearing loss (HL) (receptive communication impairment) is a known risk factor for depression. However, dysphonia (expressive communication impairment), has received little study. We study HL, self-reported voice disorder, and combined impairment as risk factors for depression in a large national cohort. This was a cross-sectional epidemiologic study. Data were analyzed from the Korean National Health and Nutrition Examination Survey (KNHANES) cycles 2008-2012 and 2019-2020. KNHANES uniquely contains both audiometry and voice disorder data. HL (yes/no) was defined as ≥25 dB pure tone average. Voice disorder (yes/no) was defined by self-report. Depression (yes/no) was defined by physician diagnosis. Odds ratios for depression were calculated using multivariable logistic regressions with HL and voice disorder. 8,524 individuals aged 19 to 80 years old had complete data. The mean age was 57.3 years (SD = 13.4) and 64% were women. All regressions were controlled for age and sex. Those with HL, versus those without, had 1.27 times the odds (95% CI = 1.07-1.52, p = 0.007) of depression. Those with self-reported voice disorder, versus those without, had 1.48 times the odds (1.22-1.78, p < 0.001) of depression. Those with HL and self-reported voice disorder, versus those with neither, had 1.79 times the odds (1.27-2.48, p < 0.001) of depression. This study demonstrates independent relationships between HL and depression and self-reported voice disorder and depression. Combined HL and self-reported voice disorder had nearly 1.8 times the odds of depression. This is likely due to the grossly additive effect of difficulty with incoming and outgoing communication streams. II Laryngoscope, 134:4060-4065, 2024.

Population characteristics and self-assessment of speaking and singing voice in Polish contemporary commercial music singers-an exploratory, cross-sectional study.

The domination of the Contemporary Commercial Music (CCM) industry in music markets has led to a significant increase in the number of CCM performers. Performing in a wide variety of singing styles involves exposing CCM singers to specific risk factors potentially leading to voice problems. This, in turn, necessitates the consideration of this particular group of voice users in the Occupational Health framework. The aim of the present research was threefold. First, it sought to profile the group of Polish CCM singers. Second, it was designed to explore the prevalence of self-reported voice problems and voice quality in this population, in both speech and singing. Third, it aimed to explore the relationships between voice problems and lifetime singing involvement, occupational voice use, smoking, alcohol consumption, vocal training, and microphone use, as potential voice risk factors. The study was conducted in Poland from January 2020 to April 2023. An online survey included socio-demographic information, singing involvement characteristics, and singers' voice self-assessment. The prevalence of voice problems was assessed by the Polish versions of the Vocal Tract Discomfort Scale (VTDS) and the Singing Voice Handicap Index (SVHI). Also, a self-reported dysphonia symptoms protocol was applied. The perceived overall voice quality was assessed by a Visual Analogue Scale (VAS) of 100 mm. 412 singers, 310 women and 102 men, completed the survey. Nearly half of the studied population declared lifetime singing experience over 10 years with an average daily singing time of 1 or 2 h. 283 participants received vocal training. For 11.4% of respondents, singing was the primary income source, and 42% defined their career goals as voice-related. The median scores of the VTDS were 11.00 (0-44) and 12.00 (0-40) for the Frequency and Severity subscales, respectively. The median SVHI score of 33 (0-139) was significantly higher than the normative values determined in a systematic review and meta-analysis (2018). Strong positive correlations were observed between SVHI and both VTD subscales: Frequency (r = 0.632, p < 0.001) and Severity (r = 0.611, p < 0.001). The relationships between most of the other variables studied were weak or negligible. The examined CCM singers exhibited substantial diversity with regard to musical genre preferences, aspirations pertaining to singing endeavors, career affiliations, and source of income. Singing voice assessment revealed a greater degree of voice problems in the examined cohort than so far reported in the literature, based on the SVH and VTDS.

Factors Associated with Self-Reported Voice Change in the Hospitalized Burn Population: A Burn Model System National Database Study.

Voice plays a prominent role in verbal communication and social interactions. Acute burn care often includes intubation, mechanical ventilation, and tracheostomy, which could potentially impact voice quality. However, the issue of long-term dysphonia remains underexplored. This study investigates long-term self-reported voice changes in individuals with burn injuries, focusing on the impact of acute burn care interventions. Analyzing data from a multicenter longitudinal database (2015-2023), self-reported vocal changes were examined at discharge and 6, 12, 24, and 60 months after injury. Out of 582 participants, 65 reported voice changes at 12 months. Changes were prevalent at discharge (16.4%) and persisted over 60 months (11.6-12.7%). Factors associated with voice changes included flame burn, inhalation injury, tracheostomy, outpatient speech-language pathology, head/neck burn, larger burn size, mechanical ventilation, and more ventilator days (p < 0.001). For those on a ventilator more than 21 days, 48.7% experience voice changes at 12 months and 83.3% had received a tracheostomy. The regression analysis demonstrates that individuals that were placed on a ventilator and received a tracheostomy were more likely to report a voice change at 12 months. This study emphasizes the need to understand the long-term voice effects of intubation and tracheostomy in burn care.

Effects of Safe and Sound Protocol on self-reported autonomic reactivity, anxiety, and depression in speech therapy clients with voice, throat, and breathing complaints

Medically unexplained oto-rhino-laryngeal symptoms (MUORLS) may have a pathophysiology related to brain-body state regulation. We use predictions from the Polyvagal Theory to investigate whether clients with voice problems have increased autonomic reactivity, anxiety, and depression. Study 1 included 54 clients with MUORLS, and a comparison group of 26 individuals without MUORLS. Outcome measures were anxiety and depression (Hospital Anxiety and Depression Scale, HADS), autonomic reactivity (Body Perception Questionnaire Short Form, BPQ-SF), and extent of voice handicap (The Voice Handicap Index, VHI) for the clients. The client group scored higher than the control group in supra-diaphragmatic reactivity, but there were no group differences in other measures. To extend the findings of Study 1, a feasibility study (Study 2) evaluated the effects of the Safe and Sound Protocol (SSP), a Polyvagal-informed protocol, on the same outcome measures. Study 2 included 33 clients with self-reported voice and throat complaints. Outcome measures assessed pre- and post-SSP were anxiety and depression (HADS) and autonomic reactivity (BPQ-SF). Results demonstrated a significant decrease in anxiety, depression, and autonomic reactivity post-SSP. In conclusion, a better understanding of the mechanisms that underlie MUORLS may provide guidance for using neurophysiologically based interventions, such as SSP, that target autonomic state regulation.

Perceptual and Acoustic Correlates of Voice in COVID-19 Infection

AbstractAccording to the information published by the World Health Organization in 2020, coronavirus disease, abbreviated as COVID-19, is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. The virus is reported to result in mild to moderate respiratory illness, significantly affecting vocal mechanisms. The present study explored the effects of a recent COVID-19 infection on perceptual, self-reported outcomes, and acoustic measures of voice. The study was conducted on 25 COVID-19-infected patients and was compared against a group of age- and gender-matched healthy individuals. Perceptual evaluation, self-reported voice outcomes using Voice Handicap Index (VHI-10), and acoustic analysis were conducted on the two groups of participants. The results revealed significant differences in perceptual and acoustic parameters of voice between the two groups.

Prevalence of and Risk Factors for Self-Reported Voice Problems in Tibetan Monks

BackgroundIt is observed that Tibetan monks pray for a long duration with inappropriate pitch and loudness. Hence, they may be prone to developing voice problems (VPs). However, the monks are not stressed and do not miss praying in the monastery (which is quite different from many other professional voice users in Western countries). Moreover, no studies have investigated the nature of VPs among Tibetan monks. Such a study may provide insight into the prevalence of and risk factors for VPs and may help enhance our knowledge of the VPs in Tibetan monks. Study DesignCross-sectional survey MethodA self-reporting questionnaire was distributed among 300 Tibetan monks residing in Namdroling Nyingmapa Monastery, Karnataka, India, from February 2023 to June 2023. Results39% of Tibetan monks experienced voice problems in their careers; hoarseness, momentary voice loss/sudden voice changes, and dryness were the most frequently reported symptoms. Monks reporting the presence of VPs also exhibited significantly higher frequencies of different phonotraumatic behaviors like speaking with a loud voice, constantly altering the voice, frequent throat clearing, speaking/chanting during throat infections, or voice problems than those who did not report VPs. The results of bivariate regression analysis identified factors such as more than eight hours of prayer duration per day, praying in the presence of musical instruments, not sipping water in between prayers, less than three litres of water intake, and the presence of acid reflux and dry throat, as significant risk factors responsible for VPs in Tibetan monks. ConclusionsCurrent results suggest that monks are at a high risk of developing VPs, and several factors (vocational, environmental, lifestyle, and health-related) contribute to the development of VPs. Further, VPs in monks also affect them in terms of missing prayers, interacting less with family/friends, and avoiding social gatherings. Overall, there is a great need to educate the monks about vocal health and preventing VPs.

Evaluation of the readability of self-reported voice disorder questionnaires*

Evaluation of the readability of self-reported voice disorder questionnaires*

Behind the Headset: Predictive Accuracy of Patient-Reported Outcome Measures for Voice Symptoms in Call Centers.

This study examines factors predicting self-reported voice symptoms in call center workers. Multivariate analysis and predictive modeling assess personal, work-related, acoustic, and behavioral factors. Generalized Linear Models (GLMs) and Receiver Operating Characteristic (ROC) curves are employed. Age and sleep patterns impacted voice quality and effort, while workplace factors influenced symptom perception. Unhealthy vocal behaviors related to tense voice and increased effort, while hydration was protective. Voice acoustics showed diagnostic potential, supported by ROC data. These findings emphasize voice symptom complexity in call center professionals, necessitating comprehensive assessment. This study recognizes its limitations, including a moderate-sized convenience sample and reliance on PROM metrics. Future research should incorporate more objective measures in addition to self-reports and acoustic analysis. This research provides novel insights into the interplay of personal, occupational, and voice-related factors in developing voice symptoms among call center workers. Predictive modeling enhances risk assessment and understanding of individual susceptibility to voice disorders. Results show associations between various factors and self-reported voice symptoms. Protective factors include sleeping more than six hours and consistent hydration, whereas risk factors include working conditions, such as location and behaviors like smoking. Diagnostic models indicate good accuracy for some voice symptom PROMs, emphasizing the need for comprehensive models considering work factors, vocal behaviors, and acoustic parameters to understand voice issues complexity.

Effectiveness and Feasibility of Telepractice on Voice Therapy for Female Teachers in Elementary Schools with Self-Reported Voice Disorders.

The purpose of this study is to explore the effectiveness of telepractice in voice intervention for female teachers in elementary schools with self-reported voice disorders. Thirty-five female elementary school teachers with self-reported voice disorders volunteered to participate in the study. They were divided into a telepractice voice intervention group (experimental group N=18) and a face-to-face voice intervention group (control group N=17) based on their employment setting. The exact same treatment protocol was applied to both groups of subjects, except that the intervention group was seen through telepractice, and the control group was seen face-to-face. The treatment protocol includes vocal hygiene education and resonant voice therapy twice a week for a total of eight sessions. Auditory perceptual analysis, acoustic assessment, aerodynamic assessment and self-assessment protocol were conducted before the intervention and one week after the last intervention, and the differences before and after interventions within each group and between groups were compared. There was no significant difference in baseline data including age, working years, and voice symptoms between the two groups. Both groups showed significant improvement (P<0.05) in all voice assessment before and after the treatment sessions, except for the Voice Handicap Index-10 (VHI-10) assessment. No statistical difference was found in other pre- and post-intervention voice assessment changes between the two study groups. The control group presented higher improvement in the total score, and the two subdomain assessments of physiology and emotion. Telepractice voice intervention can effectively improve the voice quality of female teachers in elementary schools, and telepractice therapy can be an effective alternative to face-to-face voice intervention.

Prevalence of Occupational Voice Disorder Among Teachers of Kathmandu District, Nepal.

The objective of this research was to identify the prevalence of voice disorders among teachers in the Kathmandu District of Nepal, with an emphasis on identifying possible risk factors that may be associated with these disorders. A cross-sectional study design was used, with both quantitative and qualitative data-gathering techniques using a mixed-methods approach. Data were collected from 95 non-teachers and 194 participating teachers from different schools in Kathmandu Valley. The analysis covered self-reported voice problem prevalence, job details, and demographic data. We examined the relationships between several variables and voice issues, including gender, class size, length of instruction, and tobacco usage. Findings: Compared with nonteachers (33.7%), teachers had a considerably greater prevalence of voice issues (69.1%). Greater class size and more than ten years of teaching experience were shown to be risk factors, while female instructors reported a greater prevalence of voice issues. Additionally, it was shown that instructors' voice issues are also linked to tobacco usage. The results of this study highlight how critical it is to provide voice therapy to educators employed in the Kathmandu District, particularly those in at-risk categories such as female instructors, more experienced educators, and educators with larger class sizes. The outcomes demonstrated important impacts on teacher well-being, job satisfaction, and academic achievement. More research and intervention strategies are needed to minimize the effects of voice problems and promote a positive teaching andlearning environment.

A questionnaire survey on the prevalence of self-reported voice disorders in school teachers, and classroom noise in Japan

School teachers are known as professional voice users, hence any damage to their voice or throat could compromise their work as well as their lives. We conducted a questionnaire survey of 830 teachers working at elementary schools, junior-high schools, high schools and schools for children with special needs in Saitama prefecture in Japan. We investigated the prevalence of self-reported voice disorders in teachers and how their quality of life might be influenced. We also asked the teachers to share some of their experience with noise in classrooms. We found the following three points. Firstly, more than a quarter have consulted medical doctors for problems with their voice or throat. Secondly, quality of life of female teachers are slightly more affected by their voice problems than their male peers. Thirdly, approximately 20 percent of teachers are concerned about the noise in their classrooms.

Validation of voice scales into Spanish: Systematic review of the psychometric properties

IntroductionTo use a test in a language or culture other than the original it is necessary to carry out, in addition to its adaptation, a psychometric validation. This systematic review assesses the validation studies of the voice self-report scales in Spanish. MethodsA systematic review was performed searching ten databases. The assessment was carried out following the criteria proposed by Terwee et al. (2007) together with some specifically proposed for this study. Validation studies in Spanish of self-report voice scales published in indexed journals were included and the search was updated on February 2nd, 2023. Results15 studies that evaluated 12 scales were reviewed. It was verified that not all the validations were adjusted to the criteria used and that the properties to verify the metric strength of the validations were, in general, few. ConclusionsThis systematic review shows that the included studies do not report much evidence of metric quality. It should be considered that different strategies have currently been developed to obtain more and better evidence of reliability and validity. Our contribution is to reflect on the usual practice of validation of self-report scales in Spanish language. The most important weakness is the possibility of using broader and more current evaluation protocols. We also propose to continue this work, completing it with a meta-analytic study.

Dysphonia in Pediatric Professional Voice Users: Is It Just Nodules?

Objectives/HypothesisProfessional voice users of any age are often concerned about nodules, particularly in pediatric singers. However, an accurate diagnosis allows formulation of an optimal management plan and a successful continuation of these young patients’ careers. There is very little literature regarding pediatric professional singers; we aimed to share our experience of over a decade of referrals to our tertiary pediatric voice clinic. Study DesignThis was a retrospective review. MethodsA retrospective review was undertaken of all consecutive patients aged 0–18 years who self-identified as professional voice users and attended our tertiary pediatric voice clinic between December 2010 and December 2021. We analyzed demographics, professional singing status, diagnosis, management, and clinical voice scores. The patients were subdivided into those aged 0–9, 10–16, and 17–18 years. ResultsA total of 113 pediatric professional voice users attended the tertiary voice clinic in the study period. The commonest self-reported voice use was as a singer. Within the 0–9 years age group, there was a strong male predominance (22 males and three females) and mostly organic (52%) causes. For ages 10–16 years, there was a noted female predominance (15 males and 29 females). In the 17–18 years age group, there was a strong female predominance (10 males and 34 females), with predominantly functional diagnoses (48%). Of significance, only five of the 113 patients had nodules (4.4%). ConclusionsWe present a large data set of pediatric professional voice users and demonstrate the numerous underlying diagnoses for their dysphonia, particularly functional disorders. Our experience highlights the need for adequate vocal training for pediatric professional voice users and the need for a multidisciplinary diagnostic and management approach.

University Professors’ Communicative Competence and Its Relationship With Interpersonal Communication and Voice Symptoms

To analyze the association between communicative competence self-assessment and interpersonal communication self-perception and voice symptoms in university professors. Cross-sectional, analytical, observational study in 322 professors, who answered sociodemographic and occupational questions and three self-perception protocols: Self-Assessment of Communication Competence (SACCom), Interpersonal Communication Competence Scale (ICCS), and Voice Symptom Scale (VoiSS). The dependent variable was SACCom's yes/no answers. Univariate and multivariate descriptive and inferential data analyses were performed through logistic regression. Most professors were females (55.3%), worked 40hours (96.6%), and self-reported voice symptoms (72.7%). The largest portion had been in the career for 11-22years (38.2%). The final multivariate model demonstrated that better self-assessed communicative competence among professors (SACCom) is related to an absence of voice complaints (odds ratio (OR)=2.17; 95% confidence interval (CI) 1.29-3.65) and better self-perceived interpersonal communication (ICCS) (OR=1.05; 95% CI 1.02-1.08). The older the professor (OR=1.03; 95% CI 1.01-1.06), the better their communicative competence (SACCom). Study professors' self-assessed communicative competence is predominantly high. Those with a better communicative competence self-assessment are older and vocally healthy and self-perceive greater interpersonal communication skills.

Auditory-Motor Function Pre- and Post-Therapy in Hyperfunctional Voice Disorders: A Case Series

Behavioral voice therapy is the most common treatment for hyperfunctional voice disorders (HVDs) but has limited long-term effectiveness since the comprehensive mechanisms underlying HVDs remain unclear. Recent work has implicated disordered sensorimotor integration during speech in some speakers with HVDs and suggests that auditory processing is a key factor to consider in HVD assessment and therapy. The purpose of this case-series study was to assess whether current voice therapy approaches for HVDs resulted in improvements to auditory-motor function. Longitudinal (pre-post) study. Pre and postvoice therapy for HVDs, 11 speakers underwent an assessment of auditory-motor function via auditory discrimination of vocal pitch, responses to unanticipated auditory perturbations, and responses to predictable auditory perturbations of vocal pitch. At the post-therapy session, 10 out of 11 participants demonstrated voice therapy success (via self-reported voice problems and/or auditory-perceptual judgements of voice by a clinician) and eight of the 11 participants demonstrated improvements in at least one measure of auditory discrimination and/or auditory-motor control. Specifically, three speakers demonstrated improvements in auditory discrimination, five speakers demonstrated improved (within typical cutoffs) responses to predictable perturbations, and two speakers demonstrated improvements in both auditory discrimination and auditory-motor measures. Together, these findings support that voice therapy in individuals with HVDs may impact auditory-motor control and highlight the potential benefit of systematically addressing auditory function in voice therapy and assessment for HVDs.

Prevalence of Self-Reported Voice Concerns and Associated Risk Markers in a Nonclinical Sample of Military Service Members.

Difficult communication environments are common in military settings, and effective voice use can be critical to mission success. This study aimed to estimate the prevalence of self-reported voice disorders among U.S. military service members and to identify factors that contribute to their voice concerns. A nonclinical sample of 4,123 active-duty service members was recruited across Department of Defense hearing conservation clinics. During their required annual hearing evaluation, volunteers provided responses to voice-related questions including a slightly adapted version of the Voice Handicap Index-10 (VHI-10) as part of a larger survey about communication issues. Changepoint detection was applied to age and years of service to explore cohort effects in the reporting of voice concerns. Logistic regression analyses examined multiple available factors related to communication to identify factors associated with abnormal results on the VHI-10. Among the respondents, 41% reported experiencing vocal hoarseness or fatigue at least several times per year, and 8.2% (n = 336) scored above the recommended abnormal cut-point value of 11 on the VHI-10. Factors independently associated with the greatest risk for self-reported voice concerns were sex (female), cadmium exposure, vocal demands (the need for a strong, clear voice), and auditory health measures (frequency of experiencing temporary threshold shifts; self-reported hearing difficulties). Based on self-reported voice concerns and false negative rates reported in the literature, the prevalence of dysphonia in a large sample of active-duty service members is estimated to be 11.7%, which is higher than that in the general population. Certain predictors for voice concerns were expected based on previous literature, like female sex and voice use, but frequency of temporary threshold shifts and exposure to cadmium were surprising. The strong link between voice and auditory problems has particular implications regarding the need for effective communication in high-noise military and other occupational environments.