We here in the Active English teaching community have been sharing information, resources and support to help teachers face the challenge of teaching in the hybrid and physically distanced classroom.

People who have been following me here will also know that I have started by urging everyone to make our physical and emotional health the #1 priority before worrying about how and what we are going to teach.  #maslowbeforewebloom. 

That does not just refer to the wellbeing of the students.  It also needs to be a priority for the teacher.    

In this blog post, we talk about a problem that has been affecting almost all the teachers who are back in the classroom – their vocal health.  If you are suffering from voice loss, a sore throat, changes in your voice, or struggle to be heard, please read on.

If you are a Coordinator or School director, I hope you are reading this too.  

Self-care may be the responsibility of the individual, but if you are leading a team of teachers at a school, it is your choice if you decide to make the health and wellbeing of your teachers a priority or an after-thought.  You have the choice to create policies and protocols that ensure the health, safety and emotional wellbeing of your team.  

The following content was put together by Lizzy Venables, a practicing Speech Pathologist who is based in Australia.  You can see Lizzy’s full bio at the end of the post. A list of references and additional resources which support the information in this document is provided at the end. As always, we hope you find the information here useful and interesting.  

The current literature agrees that teachers are in a high-risk group for developing voice disorders, with some studies reporting up to 50% of teachers as receiving a diagnosis of dysphonia (voice disorder) at some point in their career. This is roughly 2-3 times more prevalent than dysphonia in the general population (~15%), and more prevalent than in other professional voice user groups such as singers, fitness instructors, and actors. 

Dysphonia in teachers can lead to a number of individual and system-wide issues such as physical discomfort, teacher’s self-esteem, the intelligibility of the teacher to students, and higher rates of absenteeism and sick leave. This is why the vocal health of teachers should not just be a priority for the teachers themselves, but for team leaders, coordinators, and directors alike, as it may pose potential impacts for staffing, budgeting, and departmental wellbeing. 

Sign up for our community emails and
download the ebook with the content from this post.

Anatomy and physiology of the larynx 101 

It is essential for professional voice users to have, at least, a basic understanding of how voice is produced in the human body. 

What and where are our vocal cords?

Our vocal cords are housed within our larynx (also known as our voice box). This is a structure located at the front of our neck, just below the base of our tongue. It is connected to multiple muscles and cartilages which act as pulley systems to open and close our vocal cords to help us breath, swallow, and of course, talk!

Lyric Opera Stage Artists (2018) [A diagram of the anatomy of the larynx] https://www.lyricoperastageartists.org/2018/07/onstage-singers-health/

Encyclopedia Britannica (n.d.) [Muscles of the neck]. Larynx anatomy. https://www.britannica.com/science/thyroid-cartilage

How do vocal cords make sound? 

To phonate (make voice), the first thing we need is our breath. Air pushes up from our lungs, through our trachea (windpipe) and through the larynx. We use the complex system of muscles to close the vocal cords together, and combine this with the pressure from our breath, which causes our vocal cords to vibrate together, making sound. Our vocal cords can vibrate up to 300 times a second depending on factors such as out age, sex, and pitch.  

Why make vocal hygiene a priority?

Using our voice can be likened to exercising, and just like with exercise, there are all types of athletes. Singers, radio hosts, actors, presenters, and of course TEACHERS, are considered professional voice users, or professional athletes. To maintain vocal health and fitness, it’s essential for teachers to treat their voice like any other athlete would treat their body – with care, warm up, and training.

As Voice Care Australia puts it: “Remember, you are a Vocal Athlete!”

Warm up

It’s essential to warm up your voice before using it, just as a runner would do before a marathon or a workout. Going straight into a workout without warming your muscles first could result in more muscle fatigue, soreness, and risk of injury. It’s no different for voice users. 

How do we warm up our voices?

There are a number of different ways to safely warm up your voice. The following 5 exercises are taken from the LaTrobe University Voice Clinic. 

  • Practice abdominal breathing 
    • Breathe in slowly, pushing your stomach outwards, hold for 1 second and then breathe out slowly.  
    • Breathe in to the count of 3 (pushing stomach out always), hold 1 second, and then breathe out slowly to the count of 4. 
    • Breathe in to the count of 3, hold for count of 3, and then breathe out slowly. Breathe in slowly to the count of 4, hold briefly then breathe out very slowly to the count of 8.
  • Yawn-sigh technique 
    • Stimulate a real yawn, followed by as sigh, allowing air to be released in a relaxed manner  
    • Repeat the Yawn Sigh several times  
    • Yawn Sigh into the production of /ha/, /hu/, /hi/, /ho/
  • Vowel warm up
    • Sustain the vowel /i:/ for as long as possible on the musical note F above middle C (at your comfortable speaking pitch). Imagine the ‘knee’ sound, and feeling the sensation in your nose
    • Start with the deepest (comfortable) breath you can manage, and continue the vowel sound until you are 100% out of breath. 
  • Stretching and contracting
    • Say the word ‘woo’, glide from the lowest note you can to the highest note you can. You should have rounded lips and be able to feel vibration in your lips. 
    • Say the word ‘woo’, but this time glide from the highest note you can to the lowest note you can. You should have rounded lips and be able to feel vibration in your lips. 
  • Power exercise 
    • Say the word ‘woo’ for as long as you can. Move up a 5 step scale on the musical notes C, D, E, F, G from lowest to highest, saying each ‘note’ for as long as you can 

Hydrate 

The very best thing that you can do for your voice is to keep yourself well hydrated. There is high quality evidence for the positive effects of hydration on voice quality and endurance, and is also the most cost effective way to maintain vocal health. 

Why is hydration so important?

Moisture acts as a buffer between your vocal cords as they hit together when we talk, sing, shout. Without this moisture buffer, the delicate vocal cords are slamming and rubbing together, creating friction which creates multiple, minute injuries. Remember, vocal cords are tiny and sensitive, so repeated injury doesn’t take long to build up and create a bigger problem. 

Think of it as like a professional runner going for a run, barefoot. When the soft soles of their feet repeatedly hit the ground, they can develop painful blisters, which can turn into calluses. To protect their feet, they put on shoes and socks to act as a buffer between the ground and their foot, as well as to cushion the impact on their leg muscles. 

This is exactly the same with your sensitive vocal cords – we need that moisture buffer to cushion the repeated collision between our vocal cords, and the muscles surrounding them, to reduce friction and injury. Just like other parts of the body, vocal cords can develop blisters, known as polyps, and calluses, known as vocal nodules. Both of these things create a breathy, rough sound and can be very uncomfortable and painful to talk with. 

How do we best hydrate?

There are two types of hydration – systemic hydration, and superficial hydration. 

  • Systemic hydration = drinking water! 
    • I understand this can be a challenge for teachers at the best of times. Teachers, anecdotally, report purposely restricting their fluid intake to avoid having to take toilet breaks. This can be a result of the organisation of your school or centre. It might be difficult, but it could be worth talking to your manager or principal about how you can structure toilet breaks into your timetable. The difference between your hydration and vocal health and a 5 minute toilet break should not be up for compromise!
    • If it is not possible to replace your mask every time you eat or drink, make sure to wash your hands with soap and water before you put on your face mask (https://www.dhhs.vic.gov.au/face-masks-vic-covid-19)
    • “If you remove your mask to eat or drink, or because you are at least two metres (six feet) away from others, you should place it carefully on a clean surface or in a clean container (e.g., Tupperware) with the part that was on your mouth and nose facing up. If you use a container, be sure to clean it regularly.” (https://health.sunnybrook.ca/covid-19-coronavirus/how-to-wear-a-mask/)
    • When eating and drinking, take the following steps to remove mask:
      • Perform hand hygiene with soap and water or an alcohol-based hand rub
      • Remove the face mask and place it on a clean surface such as a paper towel or paper bag
      • Perform hand hygiene with soap and water or an alcohol-based hand rub before eating or drinking
    • After eating or drinking, take the following steps to replace the mask:
      • Perform hand hygiene with soap and water or an alcohol-based hand rub
      • Put on face mask, taking care to avoid touching face or eyes
      • Perform hand hygiene with soap and water or an alcohol-based hand rub

COVID-19 PPE: Team Member Prolonged Mask Use Prophylaxis and Treatment

  • This is new territory for everyone. Check your local health organisation for latest advice. 

Superficial, or surface hydration = humidification!

  • Inhaling steam
    • Hot (not boiling!) water in a bowl
    • Personal steam inhaler
    • Hot showers 
    • Nebulisation with isotonic saline solution (salty water) 
  • Avoiding drying environments (i.e air-conditioning or heating)
  • Using room humidifiers

Reducing strain

Straining our voice often happens when we have to use increased volume in order for our listeners to hear us. This is so common in the classroom. Think about:

  • Noisy students
  • Concurrent noise from other classrooms 
  • Music and singing
  • Behaviour management and yelling
  • Ambient and outside noise: air conditioners, heaters, fish tanks, nearby roads, computers
  • Wearing facemasks 
    • Wearing face-masks creates an additional layer of complexity and strain on the voice, because we are unable to use other aspects of communication, like facial expression, to compensate for volume. So to show our students we are happy, we might have to exaggerate our happy voices, rather than showing it through a smile. 

How can we reduce vocal strain?

  • Reduce background noise
    • Consider your classroom acoustics – e.g. laminated posters and other shiny surfaces don’t absorb sound and can amplify background noise
  • Introduce strategies to avoid raising your voice
    • Visual cueing, diagrams, and gestures 
    • Plan for regular activities that don’t require you to do the talking
  • Improve posture and breathing
    • Diaphragmatic breathing
  • Release of constriction – constriction of the vocal tracts limits airflow and vibration of the vocal cords
    • Vocal warm ups (see above)
    • Learning easy onsets
  • Voice amplification
    • Use a microphone!
    • Learn voice projection techniques (e.g. twang or belting techniques)
      • Consult a vocal coach or specialised speech pathologist for these 
  • Vocal rest
    • Schedule yourself daily periods of vocal rest
    • Avoid going from class straight to a noisy bar or restaurant, or hopping in a car or taxi and talking on the phone. 
    • Spend this time in silence, allowing your vocal folds to recuperate, recover, and rejuvenate

Reducing muscle tension

One of the biggest contributors to vocal fatigue and loss of vocal quality is muscle tension. Remember, the larynx, which houses our vocal cords, is linked with a network of muscles that connect to our shoulders, neck, jaw, face, and tongue. If one or more of these muscles are tight and stiff, this interrupts the whole network and can cause our vocal cords to function less efficiently and result in soreness and rough, breathy vocal quality . 

Think about that professional athlete – at the end of a long run or workout, it’s essential to stretch and relax to avoid muscle stiffness, lactic acid formation and sore muscles, and to improve muscle regeneration. No different to our voice! 

What causes muscle tension?

Understanding common causes of muscle tension is also how we can identify and eliminate it. 

  • Stress and anxiety
  • Strain (see above)

How can we reduce muscle tension?

Allow yourself time to stretch and relax your larynx and its surrounding muscles:

  • Progressive muscle relaxation
  • Massage
  • Mindfulness meditation
  • Diaphragmatic breathing
  • Regular exercise
  • Doing things that makes you laugh
  • Laryngeal massage (only by a trained professional, e.g. specialised speech pathologist)
  • Jaw release

Dos and Don’ts of vocal hygiene

Hydrate

  • Use steam and room humidification
  • Water is the best
  • Herbal teas and infusions
  • Naturally flavoured water e.g. fresh lemon, mint, berries
  • Avoid overly sugary drinks, including honey, as sugar can dry out the vocal tract
  • Minimise caffeine – a moderate amount of coffee/tea shouldn’t impact your voice, however ensure these drinks are not replacing other forms of hydration. A good rule of thumb is for every cup of coffee or tea, match it with a glass of water. 
  • Alcohol has a drying effect and should be minimised. It can strip the lining of our entire oral and vocal tract. 

Eliminate irritants

  • Smoking, including passive smoke
  • Alcohol
  • Avoid using medicated throat lozenges – these can have the opposite effect to what we hope!
  • Minimise sugary drinks and honey (drying effect)
  • Breath through your nose, not your mouth – the nose filters and warms the air
  • Consider if any medications are contributing to dryness (check with your doctor or pharmacist)
  • Hormonal changes may affect your vocal health (particularly for women) – discuss with your doctor if concerned
  • Consult your doctor if you have signs and symptoms of reflux (a burning sensation in the throat, post-nasal drip, frequent need to clear the throat, sensation of a lump in the throat, slow voice warm-up time, and hoarseness)

Minimise abusive vocal behaviours

  • Minimise yelling, screaming, and talking over loud noise
  • Coughing and throat clearing – these behaviours cause the vocal folds to slam together, resulting in further damage
  • If you feel a cough coming on, try sipping water, swallowing saliva, or humming, until the feeling passes
  • Avoid whispering
  • Whispering engages our false vocal folds (fibres above the vocal cords) and strains our voice further!

Keep a voice diary

  • Over a week, observe your voice and vocal habits
  • Write down how your voice sounds at different times, when it is best and when it is worst 
  • Try to work out what things affect your voice from day to day (e.g. weather, food, environment, emotions, health, amount or type of voice use). 

It is essential to know your own voice! In this way you can begin to make real, personalised changes for the better.

Consult a professional

  • General Practitioner 
  • Ear, nose and throat specialist 
  • Speech Pathologist
  • Vocal coach

**If your voice remains a problem for more than a week, please consult a General Practitioner and/or Ear Nose and Throat specialist to investigate any underlying conditions that may be contributing.**

About the Author:

Lizzy Venables has dedicated her career to helping people communicate. She has a Trinity Certificate in TESOL and a degree in Linguistics with a 1st class honors in bilingualism. After working as an english teacher in Spain and France, she went on to do a Masters in Speech Pathology. She currently works clinically in the Royal Brisbane Hospital and on the academic team at Griffith University.

References and further resources related to voice disorders in teachers and vocal hygiene:

Alves, M., Krüger, E., Pillay, B., van Lierde, K., & van der Linde, J. (2019). The effect of hydration on voice quality in adults: A systematic review. Journal of Voice, 33(1), 125.e13-125.e28. https://doi.org/10.1016/j.jvoice.2017.10.001

Aghadoost, S., Jalaie, S., Dabirmoghaddam, P., & Khoddami, S. M. (2020). Effect of muscle tension dysphonia on self-perceived voice handicap and multiparametric measurement and their relation in female teachers. Journal of Voice, https://doi.org/doi:10.1016/j.jvoice.2020.04.011

Assunção, A. Á. Bassi, I. B.de Medeiros, A. M.  de Souza Rodrigues, C. Gama, A. C. C. Occupational and individual risk factors for dysphonia in teachers, Occupational Medicine, Volume 62, Issue 7, October 2012, Pages 553–559, https://doi.org/10.1093/occmed/kqs145

de Medeiros, A. M., Barreto, S. M., & Assunção, A. Á. (2008). Voice disorders (dysphonia) in public school female teachers working in belo horizonte: Prevalence and associated factors. Journal of Voice, 22(6), 676-687. https://doi.org/doi:10.1016/j.jvoice.2007.03.008

La Trobe University (n.d.) Voice production and Voice Care information https://www.latrobe.edu.au/communication-clinic/clinical-programs/voice/how-is-voice-produced

Rossi-Barbosa, L. A. R., Ferreira Guimarães, D. H., de Souza Arantes, E., Murça de Souza, J. E., Côrtes Gama, A. C., & Caldeira, A. P. (2019). Teachers’ self-referred chronic dysphonia associated factors. Revista De Pesquisa, Cuidado é Fundamental, 11(2), 411-416. https://doi.org/doi:10.9789/2175-531.2019.v11i2.411-416

Martins, R. H. G., Pereira, Eny Regina Bóia Neves, Hidalgo, C. B., & Tavares, E. L. M. (2014). Voice disorders in teachers. A review. Journal of Voice, 28(6), 716-724. https://doi.org/doi:10.1016/j.jvoice.2014.02.008

Masson, M. L. V., & de Araújo, T. M. (2017;2018;). Protective strategies against dysphonia in teachers: Preliminary results comparing voice amplification and 0.9% NaCl nebulization. Journal of Voice, 32(2), 257.e1-257.e10. https://doi.org/doi:10.1016/j.jvoice.2017.04.013

Oates, J (1998) Voice Care for Teachers Program. La Trobe University. https://www.latrobe.edu.au/communication-clinic/resources

Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logopedics, Phoniatrics, Vocology, 32(3), 128-140. https://doi.org/doi:10.1080/14015430701207774

Pemberton, C. (n.d.) Voice Care Tips. Voice Care Australia. http://www.voicecareaustralia.com.au/hints.html

References relating to Covid-19 and mask-wearing:

Perkins, A. (2020) Team Member Prolonged Mask Use Prophylaxis and Treatment. Spectrum Health.https://www.spectrumhealth.org/-/media/spectrumhealth/documents/covid/for-providers/covid19-ppe-skin-injury-prevention.pdf?la=en&hash=EA154F2D9666C2D561A632C9F45CAACF117059CE

Sunnybrook (2020) How to wear a mask. Your Health Matters. https://health.sunnybrook.ca/covid-19-coronavirus/how-to-wear-a-mask/

Department of Health and Human Services (2020) Wearing a face mask. Face masks. https://www.dhhs.vic.gov.au/face-masks-vic-covid-19