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Vocal Higiene for the voice professional

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DOI: 10.1097/MOO.0b013e32832af105 · Source: PubMed

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Vocal hygiene for the voice professional
Mara Behlau and Gisele Oliveira
Center for Voice Studies – CEV (‘Centro de Estudos
da Voz’), São Paulo, Brazil, Department of Speech
Language Pathology and Audiology; Federal University
of São Paulo – UNIFESP (‘Universidade Federal de
São Paulo’), São Paulo, Brazil
Correspondence to Mara Behlau, PhD, CEV, Rua
Machado Bittencourt 361, São Paulo, SP 04044-001,
Brazil
Tel: +55 11 5575 1710; fax: +55 11 5575 1710;
e-mail: mbehlau@uol.com.br
Current Opinion in Otolaryngology & Head and
Neck Surgery 2009, 17:149–154
Purpose
This article presents the current state of knowledge regarding vocal hygiene for the
voice professional.
Recent findings
Research regarding vocal hygiene has primarily focused on two areas: vocal hygiene as
a preventive strategy, and vocal hygiene as a management technique for individuals
with voice disorders. It is difficult to assess the effectiveness of vocal hygiene as a
preventive tool as programs are often expensive leading to limited data. Vocal hygiene
as a sole strategy for the treatment of voice disorders has shown minimal, but
favorable results. As a component of a comprehensive therapeutic program, it is difficult
to isolate the influence of vocal hygiene. However, limited components of vocal hygiene
including hydration and vocal rest have been associated with improved therapeutic
outcomes. In addition, the current literature proposes a paradigm shift away from more
restrictive therapy approaches to a holistic approach to vocal well being.
Summary
Vocal hygiene should be considered only as a component of a broad vocal rehabilitation
program. The role of vocal hygiene as a means to prevent voice disorders remains
unproven. Additionally, some of the findings may be applied to both dysphonic and
healthy individuals in order to facilitate vocal well being.

Keywords
actors, professional voice users, singers, teachers, vocal hygiene, voice care

Curr Opin Otolaryngol Head Neck Surg 17:149–154

ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
1068-9508

modification of vocal habits and the implementation

Introduction
With the exception of professional voice users or indi-
viduals who have experienced a voice problem, many
consider voice production as a relatively abstract con-
struct and are unaware of their inherent vocal capability.
Vocal hygiene is a broad concept, typically encompassing
all facets of optimal vocal health. A comprehensive vocal
hygiene program often includes: education regarding
the vocal mechanism; identification and reduction of
phonotraumatic behaviors and high-risk vocal situations;
conservation of voice or vocal rest, controlling the
amount of talking, monitoring vocal pitch and intensity;
local lubrication and systemic hydration; optimal dietary
considerations; controlling laryngopharyngeal reflux,
gastroesophageal reflux and allergies; and minimizing
the influence of medications, environmental factors,
and lifestyle choices on voice. This program may be
employed as a preventive tool to avoid voice problems
or as a method to treat voice problems. Regardless, the
components of vocal hygiene are relatively standard,
but evolving.
Vocal hygiene as a therapeutic tool is considered a
patient-centered behavioral treatment which includes
1068-9508 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
of principles to facilitate improved vocal health [1].
Specifically, vocal hygiene, or indirect therapy [2], typi-
cally addresses both speech (loudness and quantity)
and nonspeech factors (throat clearing, yelling, crying,
laryngopharyngeal reflux, allergies, irritants and dehy-
dration) and is considered a critical component of a
comprehensive vocal rehabilitation program. However,
others suggest that vocal hygiene may be adequate
to treat voice disorders in isolation. Regardless, vocal
hygiene methods have been described in most classic
textbooks and often include lists of behaviors to avoid,
often with little or no scientific evidence. This restrictive
approach is slowly being replaced by more encouraging
methods of controlling voice production using cognitive–
behavioral techniques.
Typically the goals of vocal hygiene include increased
awareness of various aspects of voice production; how-
ever, awareness alone may not be adequate to ensure the
necessary modifications in vocal behaviors. A review of
the available literature reveals that the specific goals of a
vocal hygiene program are to teach individuals the best
practices to ensure vocal health, keeping the tissue free of
lesions, balancing muscles for a better vocal production
DOI:10.1097/MOO.0b013e32832af105

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 150 Speech therapy and rehabilitation
and achieving optimal voice. In short, the fundamen-
tal goals of vocal hygiene are to promote vocal well
being and improve communicative effectiveness [3].
Conversely, when employed as a preventive strategy,
optimal vocal habits are reinforced in order to maintain a
healthy voice and reduce injury to the vocal mechanism,
particularly for professional voice users. Both therapeutic
and preventive vocal hygiene include regular obser-
vation and consistent practice, which may affect com-
pliance.
Professional voice users include a wide range of individ-
uals whose ability to earn a living is negatively affected by
vocal impairment. Voice use may include both singing
and/or speaking voice as well as artistic or nonartistic
vocalizations, or both. The implications of poor vocal
hygiene in the development of voice problems are not
well defined. A recent Cochrane review [4] suggested
that dysphonia is associated with decreased quality of
life, and may lead to loss of work in certain populations.
The conclusion of this review [4], after analyzing
46 studies, was that the current practice of training
at-risk populations in order to prevent voice disorders
is not supported by definitive evidence of efficacy. The
authors also suggested that increased attrition is likely if
the intervention is too long [5]. Furthermore, objective
measurements of voice do not always correlate with the
client’s self-assessment [6]. These findings do not ascer-
tain that prevention is not critical in professional voice
users, but rather that well designed studies are necessary
in this regard.
Unfortunately, these reviews point out that there is
little data regarding either therapeutic or preventive
vocal hygiene. However, the main components of a
vocal hygiene program customized for the professional
voice user are outlined in the current manuscript. Specifi-
cally, we will present information regarding particular
techniques including patient education and general
guidelines for voice use, hydration, vocal rest, and vocal
warm-up and cool-down programs.
General guidelines of voice use
The majority of vocal hygiene programs include four
fundamental tenets [7]: addressing the amount and type
of voice use (extensive voice use, aberrant pitch in both
speech and/or singing, and voice use during strenuous
physical exercises); decreasing phonotraumatic behaviors
such as throat clearing, loud voice use, cheering and
screaming, speaking over background noise, and uncon-
ventional voice production; improved hydration; and
enhanced lifestyle issues leading to improved vocal
health, including elimination of tobacco, alcohol, recrea-
tional drugs and caffeinated beverages, sleeping habits,
diet, medical conditions, and medications.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Several studies have suggested that professional voice
users may benefit from didactic presentation of vocal
hygiene information, but this typically fails to alter vocal
behaviors or patients’ perception of their voices, as seen
in both untrained singers [8] and teachers [3]. A recent
study assessed subject knowledge of voice care in 17
dysphonic and 17 vocally healthy individuals [9]. Inter-
estingly, dysphonic individuals (63%) scored worse on
their knowledge of voice care than individuals with
healthy voices (72%). The dysphonic individuals agreed
less on the impact of the following factors: coughing,
drinking alcohol, loud singing, whispering, shouting,
throat clearing, and the use of medicated throat lozenges.
Despite the relatively small sample size, the study high-
lighted a consensus among clinicians and a clear differ-
ence in voice care knowledge between dysphonic and
vocally healthy individuals. In addition, levels of interest
in vocal function and dysfunction vary substantially, but
are typically higher in individuals with professional sing-
ing experience [10]. Regardless, future professional
voice users may have increased likelihood of voice pro-
blems prior to initiating their professional career as seen
in students of speech–language pathology [11] as well as
students in audiovisual communications [12,13]. How-
ever, in these studies, a long-term program including
vocal hygiene education and voice training failed to
produce desired changes in vocal habits.
Roy et al. [7] compared vocal hygiene with vocal function
exercises (VFEs) in teachers with voice disorders. At
6 weeks, improvement was observed only in individuals
submitted to direct management (VFE), even though
both groups were compliant. Vocal hygiene alone was
insufficient or may require increased duration to produce
ideal outcomes. Roy et al. [14] also compared conven-
tional vocal hygiene with the use of a portable amplifica-
tion device. No statistically significantly outcomes were
achieved. However, individuals reported improved com-
pliance with the amplification device compared with the
vocal hygiene program. Therefore, compliance was likely
a critical determinant of the outcome [7,14]. This concept
was reinforced by a recent study that compared voice
production therapy and vocal hygiene education in
women with phonotrauma [15]. Ideally, improved strat-
egies to enhance compliance must be developed to assess
the value of vocal hygiene.
Teachers represent the most studied group of pro-
fessional voice users [16] and the prevalence of voice
disorders in this group is quite high (57%). Voice use in
teachers is complex and the vocal health of teachers is
related to both psychological and behavioral factors as
highlighted by a study of 217 participants across 69
primary and secondary schools in Ireland. Three variables
were highly correlated to voice disorders (voice-related
behaviors, environment and presence of trait anxiety),

leading to novel considerations in preventive strategies
[17].
Phonotraumatic behaviors and vocal acute trauma are a
likely source of vocal impairment and professional voice
users may be at increased risk for phonotraumatic-induced
injury. Although there are no substantial data, anecdotal
reports suggest a relationship between lesion formation
and phonotrauma. Clinical reports have shown vocal fold
hemorrhage after extensive crying [18], granuloma related
to vocal behavior and tension [19,20], acute or soft-vocal
fold nodules [21], polyps [22], and even vocal-fold scar
after repetitive trauma [18,23]. One survey of physicians
and speech–language pathologists/voice specialists [24]
suggested that screaming and/or yelling is viewed as the
most hazardous vocal behavior (55%), particularly under
inadequate acoustic or physical conditions. Moreover,
voice use during a bout of laryngitis or upper respiratory
infection was considered particularly hazardous. More
recently, a striking vocal fold rupture was seen in an actor
with a sudden voice loss on stage after cold-like symptoms.
Upon resolution of this condition and extensive vocal
training, his voice returned to baseline. It is likely that a
combination of improved health and vocal rehabilitation
contributed to this outcome, but it is only a case study [25].
In spite of these data, preventive voice care remains
relatively uncommon. A recent report suggested that
preventive voice care was not a priority even among
musical performers with vocal complaints. Issues regarding
medical insurance coverage were suggested as one of the
main factors for this finding [26].
Factors potentially contributing to the development of
vocal problems, particularly with the professional voice
user may include personality and stress [27–29], high vocal
demand or aggressive vocal behaviors such as yelling,
screaming, talking too loud and crying [18,27,30–32,], lack
of recovery time after an extensive vocal use [33,34], weak
voice [35], inadequate vocal training [6,31], health con-
ditions, such as upper respiratory infections [24,35–37],
allergies [38], laryngopharyngeal reflux [39–44] and hor-
monal imbalances [45,46], aspirin and nonsteroidal, anti-
inflammatory use [46,47], and tobacco use [48]. Few stu-
dies specifically address these risk factors in professional
voice users. In addition, environmental factors may affect
the professional voice user including background noise,
poor room acoustics, distance among speakers, lack of
voice amplifiers, poor air quality (including dust parti-
cularly for teachers, actors, and performers) [17,27,32,
35], and artificial fogs and smokes [49,50]. Further inves-
tigation into these variables is warranted.
Voice constitution [51] and vocal capacity [52] are con-
cepts that require further development. It can be
assumed that anatomofunctional features and different
auditory and acoustic measures can be taken into account
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Vocal hygiene for the voice professional Behlau and Oliveira 151
when considering professional voice use. Well tolerated
limits for the quantity of vocalization are difficult to define
and it is even more complex when considering the range of
occupational categories [53]. However, preliminary data
measuring the dose of vocal-fold vibration (time, duration
and displacement) appear promising [53,54].
Hydration
Beginning in the early 1970s, it was suggested that a
relationship exists between hydration and vocal endur-
ance [55]. Hydration is typically considered as systemic
(intracellular water), topical (surface hydration, that is,
presence of water in the vocal fold mucosa), or environ-
mental. However, the relative contribution of each type
remains unclear. Data suggest that combined systemic
and environmental hydration may reduce phonation pres-
sure threshold in normal individuals [56,57] and may
reduce vocal fatigue after prolonged reading [58]. In
dysphonic individuals with benign mass lesions, manip-
ulation of environmental hydration can modify perceived
phonatory effort, vocal fold appearance and short-time
amplitude perturbation (shimmer) [59]. However, these
studies did not produce evidence regarding the amount of
vocal improvement that may be achieved with hydration,
and, furthermore, the study did not include professional
voice users. One category of professional voice user,
which is often overlooked, is the stockbroker. These
professionals have substantial vocal demands and are
exposed to reduced room temperature and humidity
(air conditioning). A large study of the stroboscopic
features of 110 stockbrokers after 6 h of work found that
73% of individuals showed improvement in parameters of
voice production following hydration treatments [60].
An interesting attempt to address the singing voice was
made with nonprofessional karaoke singers [61] and the
results suggested that hydration associated with short
periods of vocal rest might be beneficial in reducing vocal
fatigue. Unfortunately, exact guidelines for the appropri-
ate quantity and frequency of water intake have not been
described. Some texts suggest that 8–10 glasses per day are
ideal [56]. Excised canine models have been employed to
investigate the role of surface hydration [62]. These
models suggest a less clear pattern of reducing phonatory
pressure threshold with nebulized osmotic agents in vivo,
with some temporary advantageous results [63,64]. Dehy-
dration may increase the effort to phonate, which can also
increase pulmonary pressures [65]. In spite of these
encouraging preliminary data, no study has supported
hydration as an effective form of voice treatment.
Vocal rest
Historical literature has shown a clear tendency to reduce
both the amount of time and loudness of voice use. In
spite of being a controversial issue, complete voice rest is
currently limited to cases of acute laryngitis, laryngeal
 152 Speech therapy and rehabilitation
trauma, and following laryngeal surgery (not exceeding
more than few days) [66,67]. However, some physicians
do not prescribe any rest [68]. On the contrary, voice
conservation and modified vocal rest remain popular
[66,69,70]. The rationale for reducing voice use is to
promote laryngeal health in individuals with laryngeal
injuries, laryngeal pathology or vocal fatigue as well as
prevent further damage [70]. A comparison between total
and relative vocal rest after laryngeal surgery suggested
no difference in outcome [66].
Modified vocal rest programs aim to reduce the amount of
voice use and loudness and are often employed as an
introductory strategy of therapy, particularly to reduce
size of lesions [69]. A structured program of voice con-
servation, Voice Use Reduction Program – VUR [70], was
associated with improved vocal quality, reduced vocal
fatigue, and improvement in vocal-fold appearance after a
controlled period of reduced voice use. This program
facilitates key hygiene factors by calculating the maxi-
mum number of units per day and per week in a severe,
moderate, and low voice use reduction program. One
suggested modification of vocal rest is the use of whisper-
ing, but as the laryngeal configuration is variable and
vocal tract constrictions are common [71,72], it appears to
be ideal to avoid whispering.
Vocal warm-up and cool-down programs
Warm-up and cool-down programs are strategies used
before and after specific physical activities. Theoretically,
a general muscle warm-up program prepares the body and
mind for more strenuous or specific activities, improves
muscle dynamics, provides optimum preparation for per-
formance, and also prevents injury [73,74]. There is lim-
ited insight into the mechanism of warm-ups for the
muscles involved in voice production. Yet clear evidence
suggests that muscle stiffness is related to muscle injury. A
high percentage of cases (more than 30%) seen in sports
medicine clinics are due to muscle injury in both recrea-
tional and professional athletes. There are conflicting
opinions on methods of warming-up muscles, even for
large muscles required for walking or jogging. However, it
appears that warm-ups must be performed within 15 min of
activity [74]. Benefits of body warm-up are: increased
speed of muscle contraction and relaxation, greater eco-
nomy of movement due to lower viscosity resistance,
higher muscle temperatures (increasing blood flow, facili-
tating oxygen utilization, nerve transmission and muscle
metabolism), and improved mental focus on training or
competition.
Vocal warm-up is a structured sequence of exercises that
seek to ready the voice for acting, singing or any other
professional use. There are only 12 references regarding
vocal warm-up and the data are controversial regarding
the viscosity of the vocal folds (reduction of [75] or
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
increase in [76] phonatory pressure threshold; lowering
[75], no changes [77], and gender-dependent favoring
female [78]). A common trait among these studies is high
interindividual variability. A recent study comparing
specific and combined warm-up strategies for actors
showed that combined vocal and aerobic physical exer-
cises yielded more positive results for females. This
gender difference may have been influenced by the
greater level of physical fitness of males [78].
Muscle cool-down (or warm-down) strategies are less
commonly described in both the orthopedic and voice
literature. Regardless, the results are less clear than those
of warm-up exercises [79]. Theoretically, cool-down pro-
grams aim to decrease body temperature and remove
waste products from working muscles, as well as aid
in muscle relaxation, to realign fibers and to reestablish
normal range of movement, enhancing lactate clearance
and postural control [80]. One article addresses cool-
down exercises as a strategy to reduce deficits associated
with the use of speech recognition software [81]. This
area surely warrants more substantial attention.
Conclusion
The term vocal hygiene has been described in the field of
voice since its inception and has since evolved to ‘vocal
well being’, considering both the individual and the
environment. Data are limited and a systematic effort
to verify the value of vocal hygiene, as a preventive
program in professional voice users, is required. For
rehabilitation purposes, vocal hygiene should be regarded
as a mere part of a broader vocal rehabilitation program.
References and recommended reading
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been highlighted as:
 of special interest
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