Journal of Voice

Vol. 13, No. 4, pp. 602-611

© 1999SingularPublishingGroup,Inc.

Self-Reported Voice Problems Among

Three Groups of Professional Singers

*Debra Jean Phyland, Jennifer Oates, Kenneth Mark Greenwood

*School of Human Communication Sciences, La Trobe University

Victoria, Australia, School of Psychological Sciences, La Trobe University, Victoria, Australia

Summary: A vocal health questionnaire was administered to three groups of

professional singers and a "friendship-matched" group of nonsingers in Mel-
bourne, Australia. The responses of 79 opera, 57 musical theatre and 31 con-
temporary (excluding rock) singers and 86 nonsingers were analysed. The ques-
tionnaire solicited information regarding biographical data speaking and
singing voice-use behaviours, and vocal health over the previous 12 months in
terms of experiences of vocal impairment, vocal disability, and handicap. Sig-
nificant differences between singers and nonsingers in the prevalence and na-
ture of voice problems were reported. Of the singers, 44% reported one or more
occurrences of a diagnosed vocal condition compared to 21% of nonsingers and
69% of singers experienced vocal disability compared to only 41% of non-
singers, over the previous 12 months. In contrast, no significant differences
were found between the three different styles of singers in their experience of
vocal impairment, disability or handicap. Key Words: Voice disorder--
Singers--Prevalence--Style--Impairment--Disability--Handicap.

Little is known about the epidemiology of voice
disorders, particularly those that affect professional
voice users. According to Marge, when studies that
evaluate the incidence and prevalence of voice disor-
ders are compared, there is inconsistency among the
definitions of a voice problem. ~ According to the in-
ternational classification of disorders defined by the
World Health Organisation (WHO), a disorder may
Accepted for publication November 24, 1998.
Address correspondence and reprint requests to Ms. Debra
Phyland, Senior Clinician Speech Pathologist, Austin & Repa-
triation Medical Centre, Waterdale Rd, Heidelberg West 3081,
Victoria, Australia.
This work was presented at the 26th Annual Symposium:
Care of the Professional Voice, June 2-June 7, 1997, Philadel-
phia, USA.
involve impairment, disability, and handicap. 2 This
may be a useful source for the description o f voice
disorders. M a n y studies of the e p i d e m i o l o g y o f
voice disorders have not considered these three as-
pects of disorder. According to the W H O classifica-
tion, impairment is described as "any loss or abnor-
mality of psychological, physiological or anatomical
structure or function, characterised by losses or ab-
normalities that may be temporary or permanent and
not necessarily perceived by the impaired individual
as a deviation from the norm."2(p27) The resulting re-
duction in functional capacity is the disability and is
defined as "any restriction or lack of ability to per-
form an activity in the manner or within the range
considered normal."2(P28) The handicap is "a disad-
vantage for an individual, resulting f r o m an

602
 SELF-REPORTED VOICE PROBLEMS AMONG THREE GROUPS OF PROFESSIONAL SINGERS
impairment or disability that limits or prevents the
fulfilment of a role that is normal."2(p 29)
An acceptable definition of a voice disorder
would ideally distinguish vocal impairment from
Vocal disability and vocal handicap. Using the
WHO definitions, a vocal impairment is a distur-
bance of laryngeal functioning (dysphonia) that
may be characterised by acoustic, perceptual, struc-
tural, physiological, or psychological features. The
vocal disability is the resulting effect(s) of the im-
pairment on the ability to perform activities such as
speaking or singing. The handicap is the conse-
quence of this disordered output and may hence in-
clude occupational, social and economic effects. For
singers, vocal handicap may constitute inability to
perform due to vocal impairment and/or disability.
Singers are a high-risk occupational group for the
development of voice problems)~ 18 although it is not
clear from these reports whether this propensity in-
cludes all three aspects of vocal disorder (impair-
ment, disability and handicap). Despite the signifi-
cant personal, medical, financial, vocational and
medico-legal implications, the epidemiology of
voice disorders has not been established in terms of
vocal impairment, disability and handicap among
singers) 8,19 This information is crucial for the pre-
vention and management of vocal problems among
singers and other high risk voice-user groups)
Little is known about the prevalence (the number
of cases at a given point in time) of voice disorders
and even less about their incidence (the number of
new cases added to the existing population of voice
disorders per year). Marge suggested that some of
the methodological problems in epidemiological
voice research have been due to confusion between
the terms "incidence" and "prevalence," biased
sampling (often, only persons referred and seen by
otolaryngologists have been included), and the ret-
rospective nature of studies with no information
about the consistency of criteria or definitions used
for classification of voice disorders.1 Voice disor-
ders have been measured according to perceptual,
acoustic and physiological findings with little con-
sistency among studies in the measurement meth-
ods.l,21
One of the major confounders in the estimation
of the incidence or prevalence of voice disorders
among singers is the wide variability among
603
singers in their voice-use behaviours and vocal
backgrounds. Variables such as the amount and na-
ture of singing training and experience, the amount
and nature of singing demands and the perfor-
mance environments, have been shown to account
for differences among singers in their voice-use
characteristics and to significantly influence the oc-
currence of voice problems. 12-17 Many of these
variables are in turn influenced by the singing style
that a singer engages. 22-27
The purpose of the present study was to deter-
mine the prevalence of vocal impairment, disability
and handicap in three groups of singers (opera, mu-
sical theatre and contemporary [excluding rock])
and a friendship-matched group of nonsingers.
METHOD
Subjects
A total of 529 professional singers from the 3 dif-
ferent singing styles were recruited from theatre
companies, musical productions, agents, singing
teachers and venues in the Melbourne metropolitan
region. The contemporary singers were predomi-
nantly nightclub singers who performed jazz, folk,
rhythm-and-blues, a capella, and "stylist" singing
but little to no light or popular rock, country-and-
western, or heavy rock music. Because singers from
different genres have different forms of employ-
ment, means of communication and publicity, the
method for identification of potential forums for
subject recruitment was necessarily different for
each of the 3 genres. However, once the potential
sources for contacting singers were identified, the
sampling procedure was the same and followed a
random cluster approach. Due to the paucity of em-
pirical research addressing voice problems among
singers, it was not possible to conduct a formal pow-
er analysis using estimates of effect sizes and vari-
ability within the population. The sample size was
however considered to offer sufficient power to de-
tect the effects of concern to this research endeavour.
Inclusion Criteria
To satisfy the inclusion criteria, singers had to be
aged between 18 to 69 years, be professional singers
according to their own identification and have re-
ceived an income from singing in public over the
Journal of Voice, Vol. 13, No. 4, 1999
604 DEBRA JEAN PHYLAND ET AL
previous 12 months. In addition, singers were re-
quired to have sung more than 2 hours per month on
average during the previous year and have to have
sung more than 50% of their total singing time in
opera, musical theatre, or contemporary styles.
Exclusion Criteria
Singers were excluded if they were younger than
18 years or older than 69 years, if they had not sung
for the previous 12 months, and if they had sung in
public for 2 hours or less on average per month dur-
ing the previous 12 months. If potential subjects had
sung popular, country-and-western, light or heavy
rock styles more than 10% of their total singing time
during the previous 12 months, they were excluded.
The decision to exclude singers who had sung for
less than 2 hours on average per month was to focus
on those singers who either rely on their singing
voice for an income and on those who sing regularly
rather than occasionally. This decision could be criti-
cised for potentially creating sample bias because
singers with severe vocal handicap may have been
precluded from singing during the previous 12
months and hence from inclusion in the present
study. However, it is believed that this decision was
defensible in view of the major aim of this research,
namely to survey the prevalence of voice problems
among performing singers. An under-representation
of voice problems among singers was therefore con-
sidered more desirable than inclusion of singers who
had not sung during the previous year or than inclu-
sion of occasional singers.
Participating singers were asked to give a ques-
tionnaire to a nonsinger friend of the same gender
and similar age. nonsingers were excluded if they re-
ported that they sang in public during the previous
12 months or did not satisfy the same age require-
ments as those identified for the singers.
Survey Instrument
A questionnaire was designed to record singers'
vocal behaviours, vocal experience and vocal health
for 12 months. In addition, vocal disorder was de-
fined according to the following principles:
1. A voice disorder is multi-dimensional in nature
and therefore cannot be estimated from one mea-
sure only;
2. A voice disorder can be determined by the associ-
ated impairment, disability and handicap. These
Journal of Voice, Vol. 13, No.4, 1999
constituents of a vocal disorder may be similar or
different to one another in nature and severity;
3. As vocal disability and vocal handicap are sub-
jective by definition, self-report information is a
valid method of measuring these aspects of voice
problems.
The questionnaire was divided into 2 sections:
speaking and singing voice. Both sections sought de-
scriptive data and information regarding vocal im-
pairment, disability and handicap for either the
speaking or singing voice mode.
Speaking Voice Section
The speaking section asked for information re-
garding biographical details and vocal behaviours
related to the speaking voice such as the perceived
degree of talkativeness and frequency of speaking
loudly and against background noise. These were
followed by questions pertaining to vocal health,
training, and the perception of voice problems. Sub-
jects were asked to indicate whether they had experi-
enced any problem with their voice over the previ-
ous 12 months and, if so, to describe the nature of
this/these difficulties. The questionnaire then sought
information regarding specific symptoms of vocal
impairment related to subjects' speaking voices.
Subjects were asked to identify any of 10 perceptual
symptoms, and to rate the severity and impact on the
speaking voice on a 5-point Likert scale, the dura-
tion of the most severe case of each symptom, and to
then note whether they had perceived each identified
symptom as an indication of a voice problem. All of
the 10 symptoms have been identified as symptoms
of vocal dysfunction or attrition. 28-31 The subjects
were asked if they had experienced any of 7 listed
vocal disorders such as vocal nodules and voice
problem with no known medical reason, and, if so,
how frequently and who made the diagnosis.
Singing Voice Section
The singing voice section questioned the singer
about vocal category/register, singing style, amount
of performance, and singing time per month. Infor-
mation regarding performance venues in terms of
the acoustics, the background noise, degree of
smoke, and use of amplification was also sought.
Other questions pertained to the amount and nature
of singing training, the total years of singing experi-
 SELF-REPORTED VOICE PROBLEMS AMONG THREE GROUPS OF PROFESSIONAL SINGERS
ence, and the age at which the person commenced
singing in public. The singers were then asked
whether they had been unable to sing in public over
the previous 12 months because of voice problems
and, if so, the number of occasions and the duration
of the most severe occurrence of inability to per-
form. The questionnaire then sought information re-
garding specific symptoms or effects on subjects'
singing voices. Nineteen singing voice symptoms
were listed and the singers were requested to identi-
fy whether they had experienced any of these symp-
toms, and, if so, to rate the severity and impact on
the singing voice on a 5-point Likert scale, the dura-
tion of the most severe case of each individual
symptom and to then indicate whether they had per-
ceived each identified symptom as an indication of a
voice problem. All of these symptoms have been
previously identified as symptoms of vocal dysfunc-
tion or attrition related to the singing voice. 3-17
Procedure
A packet was sent to each singer that contained a
cover letter explaining the project with a confiden-
tiality statement, the address of the researcher, along
with copies of the questionnaire, ff the singers did not
wish to participate they were asked to return the sur-
vey in a reply paid envelope. Singers were asked to
give the speaking section of the questionnaire (only)
to a nonsinger friend of the same gender and similar
age. Similarly, if the nonsingers did not wish to par-
ticipate or the singers were not able to give a ques-
tionnaire to a nonsinger, they were requested to re-
turn the uncompleted survey in a reply paid
envelope.
Surveys were distributed to 529 potential partici-
pants. Of the 529 questionnaires, 205 went to musi-
cal theatre (MT) singers, 230 to opera (OP) singers,
and 94 to "contemporary--other than rock" (CO)
singers.
All recipients were asked to return the question-
naire (complete or incomplete) within 6 weeks of re-
ceipt. Where possible, the Dilman total design
method was used.31, 32 However, because many of
the packets were distributed to theatre companies or
other sources, it was not always possible to know the
date on which singers received their questionnaires
and/or whether all potential subjects received a sur-
vey. For those subjects who had not replied but had a
605
known address, a reminder letter was sent out ap-
proximately 2 months after original questionnaire
distribution. If these subjects had still not replied af-
ter 3 months from the original correspondence, an-
other reminder letter and a replacement question-
naire with reply paid envelope were sent.
RESULTS
Of the 529 questionnaires distributed, a total of
298 singers' questionnaires were retumed. The over-
all response rate according to the proportion of sur-
veys returned from the total number distributed to
singers was therefore 56.2%. Of those returned, 69
were not completed. Of the remaining 229, 15
(6.5%) were excluded from further analysis because
they did not complete essential items and an addi-
tional 43 (20.5%) were excluded because they did
not satisfy the selection criteria in terms of age (7
singers were aged younger than 18 years and 3 were
older than 69 years), amount of singing over the pre-
vious year (8 singers had not sung professionally
over the past 12 months and 11 sang for less than 2
hours per month on average, for reasons other than a
voice problem), or singing style (14 singers reported
that they sang popular, light rock or heavy rock but
not jazz, folk, musical theatre, or opera).
• In total, 171 singers' questionnaires were ana-
lyzed. Of the 171 singers, 84 reported that they sang
opera (49.8%) and 57 (33.3%) sang musical theatre
more than 50% of the total singing time. Thirty-one
singers (12.2%) were classified as "contemporary--
other than rock" if they sang any of the jazz, folk,
gospel, or rhythm-and-blues styles for more than
50% of the total singing time. None of the 'contem-
p o r a r y - o t h e r ' group sang more than 10% popular,
light or heavy rock styles.
A total of 231 nonsinger questionnaires were re-
turned, yielding a 41.5% return rate for the non-
singers. Of the 231 returned, 124 were completed.
Eleven of these were excluded because the subjects
reported that they had previous singing experience
or had been singing in an amateur capacity over the
previous 12 months. Another 27 nonsingers were ex-
cluded because their matched-singer subject was ex-
cluded for previously described reasons. Therefore,
Journal of' Voice, Vol. 13, No. 4, 1999
606 DEBRA JEAN PHYLAND E T A L
a total of 86 nonsinger questionnaires (speaking
voice only) were analyzed.
Demographics
Ninety-seven men and 160 women participated in
the study. Of the singers, 57 (34.1%) were men and
114 (65.9%) were women and, of the nonsingers, 40
(45.2%) were men and 46 (54.8%) women. There
were no significant differences in the men to women
ratio between the 3 singer groups, X2(2,171) = 1.987,
P = .37, or between the singers and nonsingers,
X2(1,257) = 2.98, p = .08. The mean age did not dif-
fer significantly, t(255) = .07, P = .51, between the
singers (35.2 _+ 11.9 years) and nonsingers (35.4 +_
12.2 years). The mean age for the opera group was
36.97 years, ranging from 18 to 72 years, for the MT
group 33.49 years, range 18 to 68 years, and for the
CO group 34.19 years, ranging from 21 to 46 years.
No significant differences in age were found be-
tween the singer groups, F(2, 168)=1.5789, P>.05.
Voice Categories, Singing Backgrounds, and
Singing Voice Use
Because the sample comprised more women than
men singers, there were more soprano, mezzo sopra-
no, and contralto voice categories represented than
tenor, baritone, bass, or falsetto. In addition, 'high'
category voices (tenor and soprano) comprised
51.8% of the voice categories, followed by 40% in
the 'medium' voice category (mezzo soprano and
baritone); whereas 'low' category voices (contralto
and bass) comprised only 6.5% of the total. The
voice categories varied significantly among the 3
groups of singer styles, X2(12,164) = 3t.33, P =
.002. There were more 'high' voices represented
within the OP group than within the MT and CO
groups. Soprano and tenor voices comprised 55.5%
of all voice categories within the OP group, com-
pared to 33.3% within the MT and 30.0% within the
CO group. Conversely, 'low' (contralto and bass)
were most frequently used by the CO group (26.7%
of all CO categories) and least used by the OP group
(2.4%).
The number of performance singing hours per
month and number of general singing hours per
month were significantly positively skewed. These
variables were transformed (using the logarithm and
square root transformation respectively) before
Journal of Voice, Vol. 13, No.4, 1999
analysis. Please note that mean values of the un-
transformed values are reported below.
A significant difference between the three groups
was found in the mean number of performance sing-
ing hours per month (F(2,164) = 23.22, P<.0001).
The MT singers performed the most hours per
month (46.5 hours), followed by the CO group (29.7
hours) and the OP group (15 hours). The groups did
not differ significantly, however, in the mean amount
of singing hours in general (including practice) per
month (F(2,168) = 2.07, P =. 13)
Singing Experience
Of the 171 singers, only 8 (4.6%) had not received
any singing training and, of the 75.5% who had re-
ceived more than 100 lessons, approximately 78%
had received more than 200 lessons. Seventy-eight
% of the singers had received classical singing train-
ing. The 8 singers with no training were comprised
of three MT and five CO singers. There were no sig-
nificant differences among the three groups with re-
gard to training, X2(2,167) = 41.851, P >.05. Howev-
er, highly significant differences among the three
styles were shown in the amount of training for
those highly-trained, F(10,163) = 41.8513, P =
0.00001. Of the trained singers within the opera
group, 61 (73.5%) were highly trained (had received
over 200 individual lessons) compared to 30
(55.5%) of the 54 trained singers within the MT
group and 4 (15.3%) of the 26 trained singers within
the CO group. Conversely, the 18 trained singers
who had received less than 20 lessons comprised
3.3% of the trained OP singers, 10.5% of the trained
MT singers and 32.2% of the trained CO singers.
The mean age at which singers commenced
singing in public was 14.2 _+ 6.98 years. The mean
years of total singing experience for all singers was
18.79 years. There were no significant differences
among the three singer groups in the mean com-
mencement age for singing, F(2,167) = 0.91, P>.05,
and the number of years of singing experience,
F(2,141) = .285, P >.05. The three singer groups were
therefore homogeneous in their reports on singing
voice experiences other than the amount of training
that they had received.
 SELF-REPORTED VOICE PROBLEMS AMONG THREE GROUPS OF PROFESSIONAL SINGERS 607

Diagnosis of Vocal Disorder
Significant differences between the singers and
nonsingers were shown for responses to questions
asking whether they had been diagnosed with a vo-
cal disorder over the previous 12 months, X2(1, N =
257) = 9.80, P = .002. Of the singers, 43.7%, com-
pared to only 21% of nonsingers, reported that they
experienced one of the seven listed voice problems
over the previous 12 months. In particular, 43% of
singers reported experience of laryngitis compared
to only 14% of nonsingers.
Singer Styles
There were no significant differences between the
three singer groups for the experience of a diagnosed
vocal disorder, X2(2, N = 171) = 2.74, P = .25. Over
half of the MT singers (51.9%) reported one or more
of the listed voice problems. Less of the opera
(40.5%) and CO (39.3%) singers reported experi-
ence of a diagnosed vocal disorder than the MT
singers but this difference was not significant. There
was, however, a significant difference between the
three groups in the prevalence of vocal nodules.
Three of the CO singers compared to one MT and
none of the OP singers reported a diagnosis of vocal
nodules. (Because the number of singers with this
diagnosis was small, the significance of results
showing group differences should be viewed with
caution). There were also trends toward differences
between the three groups in the experience of partic-
ular diagnoses (see Table 1). In particular, MT
singers reported a higher prevalence of vocal fold
oedema/swelling than the other two singer groups.
Vocal Impairment
Subjects were asked to indicate whether they had
experienced any of ten symptoms of vocal impair-
ment related to the speaking voice over the previous
12 months and, if so, to rate the severity, impact and
duration of the most severe occurrence of that symp-
tom. Subjects were then asked whether or not they
had perceived this symptom to be an indication of a
voice problem. The prevalence of each of the symp-
toms of vocal impairment is shown in "LaNe 2. For
the singers, the mean number of symptoms of vocal
impairment involving the speaking voice was 3.98 _
2.81 and for nonsingers was 4.39 __ 2.96. There were
no significant differences between the singers and
nonsingers in the mean number of symptoms of vo-
cal impairment reported for the speaking voice,
t(255) = -1.05, P >.05.
Singers were asked to indicate whether they had
experienced any of nineteen symptoms of vocal im-
pairment related to the singing voice. The mean
number of symptoms reported by the OP group was
6.33, the MT group reported a mean number of 8.16,
and the CO group reported a mean of 7.23 symp-
toms. There were no significant differences among

T A B L E 1. Frequency of Seven Diagnosed Vocal Conditions Among Three Singer Styles

Diagnosis OP % of O P MT % of M T CO % of C O

Laryngitis 18 21.5 17 29.8 4 12.9

Nodules 0 0 1 1.8 3 9.7
Oedema/swelling 4 4.7 9 15.8 3 9.7
Paralysis 1 1.2 0 0 0 0
Polyp 3 3.6 6 10.5 4 12.9
Voice problem of no 15 17.9 5 8.7 5 16.1
known medical reason
Other voice problem 2 2.4 3 5.3 2 6.5

Total with vocal condition 43 51.1 41 71.9 21 67.7

No vocal condition 41 48.9 16 28.1 10 32.3

(OP - Opera, MT = Musical Theatre, CO = Contemporary-other-than-rock)

Journal of Voice, Vol. 13, No. 4, 1999

608 DEBRA JEAN PHYLAND ET AL

T A B L E 2. Frequency of Symptoms of Vocal Impairment*

Symptom of Vocal Impairment Frequency % of Subjects

Hoarseness 193 75.1

Voice-fatigue 178 69.3
Tickling/choking sensation while speaking 138 53.6
Pain in throat 135 52.5
Change in pitch of speaking voice 114 44.3
Difficulty with volume/projection 90 35.0
Lump in throat feeling while speaking 73 28.4
Strained or strangled voice 73 28.4
Voice breaks or stops when talking 71 27.6
Complete loss of voice 30 11.6
* N = 257

the three singer styles in the number of symptoms
reported for the speaking and singing voices, F(2,
168) = 1.993, P = .140.
Vocal Disability
A significant difference between singers and non-
singers was shown for responses to the question ask-
ing whether subjects had experienced any problem
with their voice over the previous 12 months, X2(1, N
= 251) = 17.761, P = .00003. The number of singers
who responded positively was 117 (69.2%) com-
pared to 34 nonsingers (41.5%). There was, however,
no significant difference between the responses of the
three different singer groups, X2(2, N = 167) =
0.73205, P = .069, although there was a trend toward
a higher number of positive responses from the MT
group (73.7 % of MT, 67.1% of OP and 67.7% of
CO). Examination of the subjects' descriptions of the
nature of such voice problems, demonstrated that a
high proportion of these problems were reported to
be related to upper respiratory tract infections.
Vocal Handicap
A total of 46 singers (27.1% of all singers) were
unable to perform due to a 'problem with their
voice' during the previous year. Those unable to per-
form comprised 19 OP (22.9%), 19 MT (33.3%) and
8 CO (26.7%). No significant differences between
the three styles was demonstrated for the prevalence
of 'inability to perform,' X2(2, N = 170) = 1.8696, P
= .39. Of the incidents of inability to perform, the
mean annual frequency of this occurrence was 1.84
ranging from 1 to 8 occasions, and the mean dura-
tion of incidents was 23.27 days ranging from 1 to
363 days . There was no significant difference be-
tween singer groups for the frequency, F(10,45) =
8.2879, P>.05, and duration of 'inability to perform
incidents, F(2, 43) = 2.1084, P>.05.
DISCUSSION
Singers and Nonsingers
The results of the present study showed that
singers, as a group, reported a higher degree of vo-
cal disability than their 'matched' nonsingers. Using
the different aspects of disorder described in the
WHO classification, singers and nonsingers differed
in prevalence rates for diagnosed vocal conditions
and vocal disability but not for symptoms of vocal
impairment.
Diagnosed Vocal Disorders
Approximately 44 % of singers, compared to 21%
of nonsingers, reported one or more experiences of a
'diagnosed' vocal disorders over the previous 12
months. In particular, singers reported a higher num-

Journal of Voice, Vol. 13, No.4, 1999

 SELF-REPORTED VOICE PROBLEMS AMONG THREE GROUPS OF PROFESSIONAL SINGERS
bet of specific vocal conditions such as laryngitis,
vocal nodules and oedema/swelling than their
'matched' nonsingers. These prevalence figures for
both singers and nonsingers are higher than those in-
dicated by previous reports)8, 34 For example, Evans
et al reported that 22% of the MT singers/actors, but
none of the MT dancers, surveyed sought medical
attention for vocal conditions. 18 However, differ-
ences in the sampling methods and definitions of
voice disorders, as previously decribed, confound
comparison of findings across studies.
Although the validity of these reports for diag-
noses of vocal disorders has not been established,
the results suggest that singers either develop a high-
er number of vocal disorders (particularly laryngitis,
vocal nodules, and edema), are more likely to seek
medical attention for vocal impairment, or are more
likely to perceive that they have had a specific vocal
condition than nonsingers. Specifically, singers may
attach more importance to vocal changes than non-
singers, or may be more sensitized to vocal change
due to the increased vocational importance attached
to a singer's vocal status or to the increased vocal
awareness gained by training and/or performance.
The findings of this study are consistent with previ-
ous reports that singers seek medical treatment for
perceived vocal changes more readily than non-
singers.16, 33 The alternative explanation for these
findings, that singers have a higher prevalence of vo-
cal conditions than other voice-user populations
needs to be explored further using standardised, ob-
jective methods for examination of laryngeal status.
Symptoms of Vocal Impairment
The finding of no significant differences between
singers and nonsingers in the number of reported
symptoms of 'speaking voice' impairment was not
consistent with the findings of significant differ-
ences between the 2 groups in vocal disability. This
discrepancy suggests that either singers and non-
singers experience the same prevalence of vocal im-
pairment but differ in the perception of its signifi-
cance (vocal disability) or that the differences
between the two groups exist in the frequency of oc-
currence, duration and severity of symptoms, or that,
although singers experience similar symptoms of
vocal impairment for the speaking voice to the non-
singers, they experience higher rates of vocal dis-
609
ability due to problems related to the singing voice.
To the author's knowledge, the symptomatology of
vocal impairment among singers has not been previ-
ously documented. (An examination of the results of
this present study for singers and nonsingers' report-
ed frequency, severity, duration, and impact of im-
pairment symptoms will be conducted in the next
stage of the present research).
Vocal Disability
In addition to differences between singers and
nonsingers in the number of reported "diagnosed"
vocal conditions, singers (69%) were also more like-
ly to report experience of vocal disability than non-
singers (41.5%). When asked whether they had ex-
perienced a problem with their voice over the
previous year, singers gave positive responses sig-
nificantly more frequently than the nonsingers. The
results of this study clearly demonstrate that, be-
cause disability is a perceived condition, singers ex-
perienced higher amounts of vocal disability than
nonsingers. As discussed for the increased preva-
lence of diagnosed vocal conditions among singers,
this finding supports previous authors' assertions
that singers are either more likely to attach impor-
tance to any change in vocal status, even minor, or to
seek medical attention for voice problems than other
voice-user groups.l~,13,~6,33
Singing Style
Singing style did not prove to have a significant
influence on singers' experiences of vocal impair-
ment, disability or handicap. Although all singer
groups reported a high prevalence of voice prob-
lems, there were no significant differences between
the opera, musical theatre and "contemporary--oth-
er-than-rock" singer groups. Over two-thirds of each
singer group reported that they had experienced a
problem with their voice over the previous year. The
only difference in the 3 styles of singer groups was
type of diagnosed vocal condition: vocal nodules. In
addition, although not significant, there was a trend
toward a higher number of reported incidents of vo-
cal edema in the MT singers than in the other
groups.
The finding of no significant differences in the 3
different styles of singer groups in the prevalence of
voice problems was surprising, in view of previous
Journal of Voice, Vol. 13, No. 4, 1999
610 DEBRA JEAN PHYLAND E T A L
anecdotal reports in the voice literature. Many au-
thors have proposed that style of singing has a sig-
nificant influence on the development and experi-
ence of voice problems. 23-26 One possible reason for
this study's failure to replicate this finding is the ex-
clusion of popular and/or rock singers. Another ex-
planation may be the relative homogeneity of singer
subjects in the present study in terms of singing
training, experience and other variables of potential
influence on the incidence and prevalence of voice
problems among singers. Further predictive studies
are required to determine the influence of factors, re-
lated to the singers' vocal use patterns other than
singing style, on the development of voice problems.
CONCLUSION
The results of this study have clearly demonstrated
that voice disorders are multi-faceted in nature and
that vocal impairment does not necessarily correlate
with vocal disability and vocal handicap. Although
singers and nonsingers reported the same number of
symptoms of vocal impairment, the singers reported
significantly higher prevalence rates of vocal dis-
ability and of diagnosed vocal conditions than non-
singers.
As a group, singers reported high prevalence rates
of vocal disability (69%), diagnosed vocal condi-
tions (44%), and handicap as defined as "inability to
perform due to a voice problem" (27%) experienced
over the previous 12 months. These rates are higher
than predicted by anecdotal reports and may partial-
ly reflect the deliberate inclusion of common colds
and other upper respiratory tract infection in sub-
jects' estimation of voice problems. (In the authors'
clinical experiences, singers frequently used the term
"cold" synonomously with "voice problem"). Across
the three different styles of singers, however, there
were no significant differences in the self-reported
prevalence of vocal impairment, diagnosed vocal
conditions, disability and handicap. Therefore, style
of singing did not influence the prevalence of voice
problems among the singers in this study. The gener-
alizability of these findings regarding the influence
of singing style to other professional singer groups
has not been established. In particular, it is of great
interest to know whether other singer styles such as
Journal of Voice, Vol. 13, No.4, 1999
popular or rock influence the incidence or preva-
lence of voice disorders.
The epidemiology of voice problems among
singers is an area of vital importance for the preven-
tion and management of voice problems to those in-
volved in care of the professional voice. This study
offers a preliminary attempt to estimate the preva-
lence of vocal impairment, disability, and handicap
among different styles of professional singers. There
is a need for future studies that address other singing
styles such as popular and country-and-western
styles and for studies that investigate the influence of
factors related to the singing voice such as training
and amount of singing on the development of voice
problems. Finally in view of the high prevalence of
voice problems reported by the singers within this
study, there is an obvious need for the development
and implementation of eductaion programs for the
prevention and management of voice disorders
among professional singers.
REFERENCES
1. Marge M. Introduction to the prevention and epidemiolo-
gy of voice disorders. Seminars in Speech and Language.
1991;12(1):49-73.
2. World Health Organisation. International Classification of
Impairments, Disabilities and Handicaps. Geneva, Switzer-
land; 1980.
3. Sapir S, Mathers-Schmidt B, Larson GW. Singers' and
nonsingers' vocal health, vocal behaviours and attitudes
towards voice and singing: indirect findings from a ques-
tionnaire. European Journal of Disorders of Communica-
tion. 1996;31:193-209.
4. Baker, DC. Laryngeal problems in singers. Laryngoscope.
1962;72:902-908.
5. Cooper M. Vocal suicide in singers. National Association
of Teachers of Singing Bulletin. 1970;2:7-10.
6. Deinse JB, Van Frateur L, Keizer J. Problems of the
singing voice. Folia Phoniatrica. 1974;26:428-434.
7. Flach M. Indisposition und akute dysphonie beim berufs-
sanger. Laryngol Rhinol Otol. 1992;71:233-235.
8. Heuillet-Martin G. Le devenir fonctionnel des laryn-
gopathies benignes chez les chanteurs. Revue de Laryn-
gologie. 1989;110(4):391-392.
9. Lawrence VL. Vocal problems in professional users of
voice. Seminars in Speech and Language 1983;4:233-243.
10. Milutinovic Z, Bojic R Functional trauma of the vocal
folds: classification and management strategies. Folia
Phoniatrica et Logopaedica. 1996;48:78-85.
ll. Punt NA. Laryngology applied to singers. J Laryngol
Otol. 1983;6(suppl): 1-24.
 SELF-REPORTED VOICE PROBLEMS AMONG THREE GROUPS OF PROFESSIONAL SINGERS
12. Sataloff RT. Efficient history taking in professional
singers. Laryngoscope. 1984;94:1111- 1114.
13. Sataloff RT. Common diagnoses and treatments in profes-
sional singers. Ear Nose Throat J. 1987;66;28-46.
14. Sataloff RT. The professional voice: part IlL Common di-
agnoses and treatments. J Voice. 1987;1(3):283-292.
15. Sataloff RT. Surgery for the voice [editorial]. Clin Oto-
larngol. 1989;14:185-188.
16. Sataloff RT. Professional Voice: The Science and Art of
Clinical Care. New York NY: Raven Press; 1991.
17. Sataloff RT, Spiegel JR and Hawkshaw MJ. Strobovideo-
laryngoscopy: results and clinical value. Ann Otol Rhinol
Laryngol. 1991;100:725-727.
18. Evans RW, Evans RI, Carvajal S. A survey of injuries
among broadway performers. Medical Problems of Per-
forming Artists. 1996;11 (1):15-19.
19. Chmelar RD. Health insurance and worker's compensa-
tion issues and performing artists (part I). Medical Prob-
lems of Performing Artists. 1990;5(2): 67-71.
20. Chmelar RD. Health insurance and worker's compensa-
tion issues and performing artists (part II). Medical Prob-
lems of Performing Artists. 1990;3: 101-105.
21. Hirano M. Objective evaluation of the human voice: clini-
cal aspects. Folia Phoniatrica. 1989;41:89-144.
611
22. Hoit JD, Jenks CL, Watson PJ, Cleveland TF. Respiratory
function during speaking and singing in professional
country singers. J Voice. 1996;10(1):39-49.
23. Osborne CL. The broadway voice: part 1, just singin' in
the pain. High Fidelity. 1979; 28: 57-65.
24. Osborne CL: The broadway voice: part 2, just singin' in
the pain. High Fidelity. 1979:29: 53-65.
25. Shutte HK, Miller DG. Belting and pop, nonclassical ap-
proaches to the female middle voice: some preliminary
considerations. J Voice. 1993;7:142-150.
26. Batza EM. Vocal abuse in rock and roll singers: report of
five representative cases. Cleveland Clin Q. 1971;38:35-38.
27. Cornut G, Bouchayer M. Les therapeutiques phoniatriques
de la voix chantee. Revue de Laryngologie. 1985;106(4):
289-294.
28. Bastian RW, Keidar A, Verdolini-Marston K. Simple vocal
tasks to detect vocal fold swelling. J Voice. 1990;4
(2):172-183.
29. Sapir S, Vocal attrition in voice students: survey findings.
J Voice. 1993;7(1):69-74.
30. Sapir S, Attias J, Shahar A. Vocal attrition related to idio-
syncratic dysphonia; re-analysis of survey data. Eur J Dis-
ord Commun. 1992;27:129-135.
31. Dillman DA. Mail and other self-administered question-
naires. In: Rossi PH, Wright JD, Anderson AB, eds. Hand-
Journal of Voice, Vol. 13, No. 4, 1999