Voice Complaints Research Articles

Voice, stress, work and quality of life of soccer coaches and physical trainers.

To assess aspects related to work, stress and quality of life related to voice in soccer coaches (C) and physical trainers (T), comparing the categories. Qualitative and quantitative studies with 13 C and 13 T of teams competing in Phase One of the highest level (Série A ) of the 2012 Campeonato Paulista (São Paulo State Soccer Championship). The questions were open ended and related to complaints, difficulties, and/or problems regarding voice use during work and to the relations between voice, work, stress, and quality of life. Stress at work was analyzed by the Job Stress Scale (JSS) questionnaire. The perception of the impact of the voice on quality of life was evaluated by the Voice-Related Quality of Life (V-RQOL) protocol. The answers to the questions were transcribed and submitted to content analysis, and regarding the questionnaire, descriptive data and analytical statistics were used. Content analysis showed lack of preparation for voice care; voice complaints; and intense vocal use demand under stressful work, in addition to the absence of healthy habits and social/family support. The JSS dimensions showed that the Active Work situation and the high V-RQOL scores are compatible with vocal health without complaints. There were no statistical differences between the categories. Both categories reported complaints/problems linked to professional voice use and stressful workload. However, the perception of vocal impact on the quality of life was positive, and the analysis of stress at work resulted in "good" and favorable conditions. The relationship between voice, work, stress, and quality of life in both the categories require further investigations.

Behavior, Social Competence, and Voice Disorders in Childhood and Adolescence

This study aimed to verify the relationships among voice change complaints, indicators of competence, and behavioral problems in children and adolescents. This is a prospective study. A sample of 103 parents/guardians completed the Child Behavior Checklist for ages 6-18 years. The mean age and gender were very similar between the participants with and without voice complaints. Regarding the competences, no differences were found between the participants with and without voice complaints. The group with voice complaints presented higher total scores and T-scores in the both anxiety/depression and somatic complaints domains and in the internalising, externalizing, and total scales. The total scores and T-scores on the internalising, externalizing, and total scales, as well as those of their domains (anxiety/depression, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior), differed between children and adolescents with and without voice complaints. Children and adolescents with complaints of voice disorder demonstrate a potential risk of developing emotional/behavioral problems.

Main vocal complaints of elderly patients after leprosy treatment

SummaryLeprosy is an infectious disease, with vocal involvement varying between hoarseness and difficult breathing.Aimcompare the main vocal complaints among elderly patients after treatment for leprosy and a control group.Study designdescriptive prospective.Materials and methodsWe included 50 patients aged over 60 years, 32 had been treated for leprosy, and the others formed the control group. We used our own questionnaire to analyze the vocal symptoms presented by the two groups, as well as gender, age, life style and comorbidities.Resultsamong the treated group, the most frequent symptoms were hawk (34.4%) and hoarseness (28.1%), while in the control group the most prevalent symptoms were hoarseness (77.8%) and a foreign body sensation (55.6%).Conclusionthe most prevalent voice complaints in patients treated for leprosy are hawking and hoarseness, and that its development is influenced by life style and associated diseases.

Tempo de tratamento em fonoaudiologia em um serviço público versus balizadores preconizados

Resumo: OBJETIVO: verificar a adequação do tratamento fonoaudiológico quanto ao tempo, à duração e à frequência em um serviço público municipal de acordo com os balizadores propostos pelo Conselho Federal de Fonoaudiologia. MÉTODOS: trata-se de um estudo transversal observacional retrospectivo com análise dos prontuários dos indivíduos de 0 a 14 anos atendidos pelo setor de Fonoaudiologia de um serviço público municipal no período de 2007 a 2012. RESULTADOS: destaca-se, entre seus achados, a prevalência do sexo masculino (66,9%); adolescentes (47,0%); queixa mais frequente: a de Linguagem (86,5%) e encaminhamentos realizados por profissionais médicos (49,1%), seguido por educadores (22,7%) e fonoaudiólogos (20,4%). Com relação à adequação dos balizadores tempo e duração, o sexo feminino apresentou percentual significantemente superior, quando comparado ao masculino; porém, não se encontraram diferenças em relação ao balizador frequência. O balizador tempo apresentou melhores resultados, porém distantes dos valores preconizados; a não conformidade foi maior para as queixas de audiologia, motricidade orofacial e voz. Os piores resultados foram para o balizador frequência, sendo que a queixa de voz apresentou 50% de adequação. CONCLUSÕES: considera-se importante o investimento no planejamento de ações em saúde fonoaudiológica neste serviço, voltado principalmente para a frequência das sessões e para a queixa de linguagem, priorizando a qualidade de vida da população atendida.

Evaluando la salud laboral de los docentes de centros concertados: el Cuestionario de Salud Docente

The aim of the present study was to evaluate the psychometric properties of the Perceived Health Questionnaire for Teachers (CSD) in a sample of 6,208 teachers of subsidised state schools in Catalonia. Exploratory factor analysis sheds light on six factors: exhaustion, voice complaints, musculoskeletal complaints, cognitive complaints, satisfaction, and self-efficacy. Confirmatory factorial analysis results indicate a good fit to the model. All factors have high reliability indices. It is concluded that the CSD shows adequate psychometric properties to contribute to the institutional surveillance of teachers’ health. Guidelines are provided for future research.

Prevalence of Voice Disorders and Associated Risk Factors in Teachers and Nonteachers in Iran

Teachers are at increased risk for development of voice disorders. Because there is no published study on Iranian teachers, the aim of this study was to compare the prevalence of voice disorders among teachers and nonteachers in Iran and define the causing risk factors. In the present study, 104 teachers and 41 nonteacher participants, whose jobs did not involve vocal effort, completed a questionnaire regarding to vocal complaint and four relevant risk factors. According to our gained data, 54.6% of teachers experienced vocal complaints during their work, although this value was 21.1% for the nonteacher group (P<0.001). Moreover, investigating the prevalence of voice disorders during other periods of life was performed. Analyzing the questionnaire data indicated a significant higher vocal load risk factor for teachers (70.77%; standard deviation [SD], 29.48), in comparison with their nonteacher counterparts (27.44%; SD, 37.83; P<0.001). In addition, our study revealed the significance of vocal load, as well as physical and environmental risk factors in the development of voice disorders in teachers with voice complaints. Present findings indicated a higher epidemiology of voice problems among teachers in comparison with nonteacher individuals and introduced vocal load as the most important risk factor in development of voice disorder in Iranian teachers. Accordingly, it is recommended to pay special attention to negative effects of vocal load, although environmental and physical factors are also of importance.

Do Talkativeness and Vocal Loudness Correlate With Laryngeal Pathology? A Study of the Vocal Overdoer/Underdoer Continuum

Assess the correlation between self-rating scales of talkativeness and loudness with various types of voice disorders. This is a retrospective study. A total of 974 patients were analyzed. The cohort study included 430 consecutive patients presenting to the senior author with voice complaints from December 1995 to December 1998. The case-control study added 544 consecutive patients referred to the same examiner from January 1988 to December 1998 for vocal fold examination before thyroid, parathyroid, and carotid surgery. Patient responses on seven-point Likert self-rating scales of talkativeness and loudness were compared with laryngeal disease. Mucosal lesions clearly associated with vibratory trauma are strongly associated with a high self-rating of talkativeness. Laryngeal deconditioning disorders were associated with a low self-rating of talkativeness. Use of a simple self-rating scale of vocal loudness and talkativeness during history taking can reliably orient the examiner to the types of voice disorders likely to be diagnosed subsequently during vocal capability testing and visual laryngeal examination. The high degree of talkativeness and loudness seen in vocal overdoers correlates well with mucosal disorders such as nodules, polyps, capillary ectasia, epidermoid inclusion cysts, and hemorrhage. A lower degree of talkativeness correlates with muscle deconditioning disorders such as vocal fold bowing, atrophy, presbyphonia, and vocal fatigue syndrome.

A Comparison of Initial and Subsequent Follow-Up Strobovideolaryngoscopic Examinations in Singers

Previous studies have identified abnormal findings in up to 86.1% of singers on initial screening strobovideolaryngoscopy (SVL) examinations. No studies have compared the prevalence of abnormalities in singers on their subsequent follow-up SVL. Our study evaluates the frequency of these findings in both the initial and subsequent examinations. Retrospective charts and SVL reports were reviewed on students from an opera conservatory from 1993 to 2014. All students had initial screening SVL, but only students who later returned with acute voice complaints were included in the study (n=51, 137 follow-up visits). Normal SVL was defined as an examination without structural or functional abnormalities and reflux finding score ≤7. Data were analyzed using the chi-square test. For initial examinations, 90.2% (including reflux) and 88.2% (excluding reflux) were abnormal. In follow-up examinations, 94.9% (including reflux) and 94.2% (excluding reflux) had abnormal findings, which included muscle tension dysphonia (40.1%), vocal fold (VF) masses (unilateral 48.9%, bilateral 30.7%), vascular abnormalities (unilateral 27.0%, bilateral 5.8%), sulcus (unilateral 17.5%, bilateral 5.1%), VF hypomobility (unilateral 36.3%, bilateral 5.9%), phase (30.6%) and amplitude (44.8%) asymmetries, and glottic insufficiency (49.3%). Follow-up examinations revealed a significant increase in laryngopharyngeal reflux (χ(2)=7.043; P<0.05). We found a higher prevalence of abnormal findings compared with previous studies, which we attributed to a more inclusive definition of abnormal pathologies, improvements in SVL technology, and possibly increased experience with SVL interpretation. This high prevalence of abnormal findings in asymptomatic singers further supports the importance of baseline examinations.

Evaluation of the prevalence of and factors associated with laryngeal diseases among the general population.

Despite the high prevalence of voice disorders, the prevalence of laryngeal disease in the general population has not been determined using laryngoscopy. Factors considered associated with laryngeal disease have mostly been assessed using patient data or highly specific populations. We evaluated the prevalence of and associated factors with laryngeal diseases in the general Korean population. Cross-sectional study. We analyzed data from the Korea National Health and Nutrition Examination Survey for 19,039 participants assessed between 2008 and 2011. The prevalence, subjective discomforts rates of, and odd ratios (demographics, life-style factors, and diseases factors) for laryngeal disease were analyzed using simple and multiple logistic regression analyses, taking into account the complex sampling structure of the data. The top five laryngeal diseases in prevalence were laryngitis (3,513/100,000), vocal nodules (1,487/100,000), vocal polyp (404/100,000), Reinke's edema (347/100,000), and epiglottic cyst (296/100,000). Prevalence of laryngeal disease was higher in males, whereas the rate of subjective voice complaints was higher in females. In the logistic regression analysis, gender was not associated with laryngeal diseases after adjusting for other factors. We observed a positive association between low body mass index (BMI) and vocal nodules, and between high BMI and laryngitis, smoking and epiglottic cyst/hyperkeratosis/laryngeal cancer, higher education level and vocal nodules, and allergic rhinitis and vocal nodules/laryngitis/epiglottic cyst. The rate of subjective voice complaints and laryngeal disease co-occurrence was low. This study provides more reliable information of laryngeal disease because it includes participants without subjective complaints. 2b.

Medical Costs and Productivity Costs Related to Voice Symptoms in Colombian Teachers

To investigate the medical costs and productivity costs of voice symptoms among teachers and to assess the contribution of the characteristics of voice symptoms, sociodemographic characteristics, health conditions, and work-related factors to these costs. This is a cross-sectional study. In 2012, we conducted a longitudinal study in 12 public schools in Bogotá D.C., Colombia. This study is focused on cross-sectional results obtained in the first stage of the data collection process. Participants filled out a questionnaire on sociodemographics, voice symptoms, work-related conditions, use of health care, productivity loss at work, and sickness absence. Multiple logistic regression analysis was used to explore associations among health care use, voice-related absenteeism and productivity loss with duration and severity of voice symptoms, sociodemographic characteristics, health conditions, and work-related factors. In total, 621 Colombian teachers participated in this research, 438 of whom had self-reported voice complaints and who therefore made up the study population. Total medical costs and productivity costs due to presence of voice symptoms among teachers with voice complaints equaled around 37% of their monthly wage. Approximately, 3% of the costs were direct costs for health care use, and 97% were indirect costs for productivity losses. Severity of voice symptoms was significantly associated with health care use and absenteeism. Voice symptoms among teachers have important economic consequences because of health care use, voice-related absenteeism, and productivity loss at work.

Hoarseness in School-Aged Children and Effectiveness of Voice Therapy in International Classification of Functioning Framework

The hoarseness in school-aged children disrupts the educational process because it affects the social progress, communication skills, and self-esteem of children. Besides otorhinolaryngological examination, the first treatment option is voice therapy when hoarseness occurs. The aim of the study was to determine the factors increasing the hoarseness in school-aged children by parental interview and to know preferable voice therapy on school-aged children within the frame of International Classification of Functioning (ICF). Retrospective analysis of data gathered from patient files. A total of 75 children (56 boys and 19 girls) were examined retrospectively. The age range of school-aged children is 7-14 years and average is 10.86 ± 2.51. A detailed history was taken from parents of children involved in this study. Information about vocal habits of children was gathered within the frame of ICF and then the voice therapies of children were started by scheduling appointments by an experienced speech-language pathologist. The differences between before and after voice therapy according to applied voice therapy methods, statistically significant differences were determined between maximum phonation time values and s/z rate. The relationship between voice therapy sessions and s/z rate with middle degree significance was found with physiological voice therapy sessions. According to ICF labels, most of voice complaints are matching with "body functions" and "activity and limitations." The appropriate voice therapy methods for hoarseness in school-aged children must be chosen and applied by speech-language therapists. The detailed history, which is received from family during the examination, within the frame of ICF affects the processes of choosing the voice therapy method and application of them positively. Child's family is very important for a successful management.

The Effectiveness of the Comprehensive Voice Rehabilitation Program Compared With the Vocal Function Exercises Method in Behavioral Dysphonia: A Randomized Clinical Trial

To evaluate the effectiveness of the Comprehensive Voice Rehabilitation Program (CVRP) compared with Vocal Function Exercises (VFEs) to treat functional dysphonia. This is a randomized blinded clinical trial. Eighty voice professionals presented with voice complaints for more than 6months with a functional dysphonia diagnosis. Subjects were randomized into two voice treatment groups: CVRP and VFE. The rehabilitation program consisted of six voice treatment sessions and three assessment sessions performed before, immediately after, and 1month after treatment. The outcome measures were self-assessment protocols (Voice-Related Quality of Life [V-RQOL] and Voice Handicap Index [VHI]), perceptual evaluation of vocal quality, and a visual examination of the larynx, both blinded. The randomization process produced comparable groups in terms of age, gender, signs, and symptoms. Both groups had positive outcome measures. The CVRP effect size was 1.09 for the V-RQOL, 1.17 for the VHI, 0.79 for vocal perceptual evaluation, and 1.01 for larynx visual examination. The VFE effect size was 0.86 for the V-RQOL, 0.62 for the VHI, 0.48 for the vocal perceptual evaluation, and 0.51 for larynx visual examination. Only 10% of the patients were lost over the study. Both treatment programs were effective. The probability of a patient improving because of the CVRP treatment was similar to that of the VFE treatment.

Voice training for professional voice users

&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Background: &lt;/span&gt;&lt;/strong&gt;A professional voice user is defined as an individual who depends on the use of his or her voice to earn a living, and nowadays encompasses a gamut of professions ranging from highly skilled artistes to call center workers. All of them have various levels of vocal demand but not all are suitably equipped to meet these demands because of a lack of formal training. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Methods: &lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt;This study was conducted as a short-term project under the auspices of the ICMR (Indian Council of Medical Research). The principal investigator is the first author, an undergraduate medical student, while the corresponding author is the faculty who guided the student in this endeavor. With a view to exploring how voice training, as opposed to voice therapy for a specific complaint or lesion, could improve the outcome and performance of a professional voice user with no prior training, we carried out this study in our institution and in a nearby school and college.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Results: &lt;/span&gt;&lt;/strong&gt;Over half the subjects were found to have a complaint about their voice. There were equal numbers of men and women in this study and the age group of 26-30 years was the best represented. This age group is significant as it represents the start of the working life of a typical individual, in this case the professional voice user. A positive correlation was found between increasing age (and years of work experience) and the frequency of a voice complaint. With years of work experience more than 15 years, the frequency of voice problems decreased slightly. On cross checking, it was found that these persons were in more senior levels of work, and so had less work pressure.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Conclusions: &lt;/span&gt;&lt;/strong&gt;This study shows that voice training has to be imparted over a considerable period of time even for the less skilled group of professional voice users. &lt;/p&gt;&lt;p class="keywords"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Keywords: &lt;/span&gt;&lt;/strong&gt;Voice assessment, Voice training, Professional voice user&lt;/p&gt;

Vocal Fold Paralysis as a Delayed Consequence of Neck and Chest Radiotherapy.

To describe a series of cases of vocal fold paralysis years after radiation therapy, including presentation, clinical course, and treatment. Case series with chart review. Tertiary care center. A review of 8 years of patient records yielded 10 patients (8 male and 2 female; average age 57 years [range, 29-76 years]) with vocal fold paralysis and a history of radiation therapy to the head, neck, or mediastinum. These patients did not have other possible etiologies of vocal fold paralysis. Demographic, diagnostic, clinical course, and treatment data were collected. On average, 21 years (range, 1-27 years) elapsed between completion of radiation and presentation with vocal fold paralysis. Original pathologies included Hodgkin lymphoma (5), squamous cell carcinoma of the head and neck (4), and peripheral T-cell lymphoma (1). Eight patients had unilateral left vocal fold paralysis, and 2 had bilateral neuropathy; none recovered spontaneously. All patients had dysphonia, and nearly all patients also complained of dysphagia. Six elected not to be treated. Four underwent injection augmentation with resolution of voice complaints. Radiation therapy has the potential to cause laryngeal neuropathy years to decades after treatment. The potential for recovery is low, but injection augmentation can relieve symptoms. Development of contralateral neuropathy and altered tissue response are considerations in treatment.

Substernal goiter: when is a sternotomy required?

BackgroundSternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach to thyroidectomy. We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG and analyzed the preoperative and postoperative characteristics of patients with SSG compared with those with large goiters contained entirely within the neck or a cervical goiter. MethodsA retrospective review of a surgical database was performed. We included patients with large (>100 g) thyroids or SSG, regardless of size. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had an SSG and patients who had a cervical goiter with particular focus on those who required sternotomy. ResultsOf the 220 patients, 127 patients (58%) had SSG, of whom 7 (5.5%) required sternotomy. All patients who underwent sternotomy underwent preoperative computed tomography scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints and have extension of the thyroid gland below the aortic arch. Sternotomy took an average of 2 hours longer than a cervical incision, was associated with significantly more blood loss (600 versus 190 mL, P = 0.04), and a longer length of stay (3.1 versus 1.8 d, P = 0.03) than cervical thyroidectomy. ConclusionsSternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch and were more likely to present complaining of chest pressure and voice issues.

Vocal Fatigue Index (VFI): Development and Validation

To develop a psychometrically sound self-report questionnaire, the Vocal Fatigue Index (VFI), to help identify individuals with vocal fatigue (VF) and characterize their complaints. Descriptive research-scale development. Four laryngologists and six speech-language pathologists specialized in voice created a beta version of the VFI (version 1), an index of 21 statements they considered to reflect VF. Two hundred patients presenting to two different clinics completed the VFI-1. Two items from VFI-1 were excluded because of poor item-to-total correlations. The final VFI of 19 items (version 2), completed by 105 patients with voice complaints and 70 vocally healthy individuals, was assessed for its psychometric properties. Test-retest reliability for the final VFI was generally strong, as was sensitivity and specificity using the classification table under logistic regression for correctly distinguishing individuals with and without VF. Moreover, factor analysis indicated that VF may be characterized by three factors: (1) factor 1, related to tiredness of voice and voice avoidance, (2) factor 2, related to physical discomfort associated with voicing, and (3) factor 3, related to improvement of symptoms with rest. The VFI is a standardized tool that can identify individuals with probable VF with good reliability, validity, sensitivity, and specificity.

The Prevalence of Voice Disorders in 911 Emergency Telecommunicators

Emergency 911 dispatchers or telecommunicators have been cited as occupational voice users who could be at risk for voice disorders. To test the theoretical assumption that the 911 emergency telecommunicators (911ETCs) are exposed to risk for voice disorders because of their heavy vocal load, this study assessed the prevalence of voice complaints in 911ETCs. A cross-sectional survey was sent to two large national organizations for 911ETCs with 71 complete responses providing information about voice health, voice complaints, and work load. Although 911ETCs have a higher rate of reported voice symptoms and score higher on the Voice Handicap Index-10 than the general public, they have a voice disorder diagnosis prevalence that mirrors the prevalence of the general population. The 911ETCs may be underserved in the voice community and would benefit from education on vocal health and treatments for voice complaints.

Preoperative laryngoscopy in thyroid surgery: Do patients' subjective voice complaints matter?

Although routine preoperative laryngoscopy has been standard practice for many thyroid surgeons, there is recent literature that supports selective laryngoscopy. We hypothesize that patients' preoperative voice complaints do not correlate well with abnormalities seen on preoperative laryngoscopy. A retrospective chart review of a 3-year, single-surgeon experience was performed. Records of patients undergoing thyroid surgery were reviewed for patient voice complaints, prior neck surgery, surgeon-documented voice quality, and results of laryngoscopy. Of 464 patients, 6% had abnormal laryngoscopy findings, including 11 cord paralyses (2%). Preoperatively, 39% of patients had voice complaints, but only 10% had a corresponding abnormality on laryngoscopy. Only 4% of patients had a surgeon-documented voice abnormality with 72% corresponding abnormalities on laryngoscopy, including 8 cord paralyses. When eliminating patient voice complaints and using only history of prior neck surgery and surgeon-documented voice abnormality as criteria for preoperative laryngoscopy, only 1 cord paralysis is missed and sensitivity (91%) and specificity (86%) were high. Also, when compared with routine laryngoscopy, 84% fewer laryngoscopies are performed. When using patients' voice complaints as criteria for preoperative laryngoscopy, the yield is low. We recommend using surgeon-documented voice abnormalities and history of prior neck surgery as criteria for preoperative laryngoscopy.

Determinants of Customer Complaint Behavior in a Restaurant Context: The Role of Culture, Price Level, and Customer Loyalty

Prior cross-cultural research on customer complaint behavior has shown that Asian customers–collectivists (vs. Western customers–individualists) are less likely to engage in voice complaint but more inclined to choose nonconfrontational responses such as switching and negative word-of-mouth. Yet, we suggest that this relationship may not hold true when taking into account customer loyalty, price level, and power distance as cultural value. To that end, we conducted an experiment to examine the joint effects of culture, customer loyalty, and restaurant price level on customer complaint behaviors. Our results indicate that Asian customers might indeed be vocal public complainers when there is no deep commitment to a restaurant and when paying a high price for the service. Theoretical and practical implications are also discussed.

Comparação entre formas de extração do tempo máximo fonatório em indivíduos sem queixas vocais

OBJETIVO:verificar a confiabilidade entre um programa de análise acústica, um avaliador com experiência e um avaliador sem experiência na área para medição do TMF da vogal /a/ em sujeitos sem queixas vocais. Verificar se há diferença entre o maior valor das três emissões do TMF com a média desses valores.MÉTODOS: 56 adultos realizaram emissão e gravação da vogal /a/ em TMF. Uma medição foi realizada por um fonoaudiólogo com experiência e outra por um fonoaudiólogo recém-formado, ambos utilizando um cronômetro. Um terceiro avaliador realizou a medida em um programa de análise acústica. Comparou-se a diferença entre os valores encontrados para a mesma emissão e o maior valor de TMF obtido com a média resultante das três emissões para cada indivíduo.RESULTADOS:não houve diferença entre os avaliadores e o programa de análise acústica. Há diferença estatisticamente significante na definição do TMF, considerando-se a média das três emissões ou seu maior valor.CONCLUSÃO:o TMF tem grande confiabilidade independentemente da forma de extração e da experiência clínica do avaliador. Houve diferença no valor do TMF quando comparado à média de três emissões com a maior emissão, o que sugere que se deve sempre seguir o mesmo padrão nas avaliações e reavaliações, evitando vieses.