Published online: 2019-12-13 THIEME Original Research 323 Vocal Tract Discomfort Scale (VTDS) and Voice Symptom Scale (VoiSS) in the Early Identification of Italian Teachers with Voice Disorders Bruno Galletti1 Federico Sireci1,2 Roberta Mollica1 Elisabetta Iacona3 Francesco Freni1 Francesco Martines Enrique Perellò Scherdel5 Rocco Bruno1 Patrizia Longo1 Francesco Galletti1 4 1 Department of Adult and Development Age Human Pathology Address for correspondence Federico Sireci, MD, Department of “Gaetano Barresi,” unit of otorhinolaryngology, University of Adult and Development Age Human Pathology “Gaetano Barresi,” Messina, Messina, Italy unit of Otorhinolaryngology, University of Messina, Via Consolare 2 Section of ENT, ARNAS Fatebenefratelli Hospital, Palermo Italy Valeria 1, 98125, Messina ME, Italy (e-mail: federicosireci@hotmail.it). 3 Section of Audiology, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy 4 Department Bio.Ne.C., Section of ENT, University of Palermo, Palermo Italy 5 Servicio de Otorrinolaringologia, Hospital General Universitari vall D’Hebron Universitat Autonoma de Barcelona, Catalunya, Spain Int Arch Otorhinolaryngol 2020;24(3):e323–e329. Abstract Introduction The current Italian law does not include any guidance regarding voice education, prevention of voice disorders and screening in subjects with high vocal loading such as teachers. Objectives We aimed to check the correlation between the Vocal Tract Discomfort Scale (VTDS) with the Voice Symptom Scale (VoiSS) for the evaluation of Italian teachers. In addition, we aimed to investigate whether there are differences in the frequency and intensity of discomfort symptoms in teachers with disabilities compar- ing vocal tract discomfort symptoms in teachers with high risk (HRVD) and low risk (LRVD) of vocal disorders according to the VoiSS cutoff (> 15.5). Methods We analyzed 160 Italian teachers (111 women and 49 men) that completed the VTDS and VoiSS at vocal evaluation. The Spearman correlation test was applied to all variables. The Mann-Whitney U test was used to compare the average number of discomfort symptoms among HRVD and LRVD teachers. Results A moderate positive correlation was observed between the average number, frequency, and intensity of discomfort symptom and the total score, physical domain score, and limitation domain score of the VoiSS. Only the emotional domain score of the VoiSS showed a weak positive correlation (p < 0.001). Teachers considered in the HRVD group according to the VoiSS score had a higher number, frequency, and Keywords intensity of vocal tract discomfort symptoms. ► voice disorders Conclusion There is correlation between the VTDS and VoiSS scales. Like the VoiSS, ► VoiSS the VTDS is a questionnaire that detects HRVD teachers. Therefore, the results suggest ► VTDS that both questionnaires could be useful for a preventive voice program for Italian ► teachers teachers received DOI https://doi.org/ Copyright © 2020 by Thieme Revinter February 15, 2019 10.1055/s-0039-1700586. Publicações Ltda, Rio de Janeiro, Brazil accepted ISSN 1809-9777. September 17, 2019 published online December 13, 2019 324 Vocal Tract Discomfort Scale (VTDS) and Voice Symptom Scale (VoiSS) Galletti et al. Introduction So far, in Italy, the VoiSS and VTDS are questionnaires diffused among the professional categories at risk for voice The voice represents an instrument for professionals that disorders, but there are few data in the literature especially for conduct activities involved in communication, information, teachers. Amaral et al1 divided teachers according to the cutoff art, culture, education and politics. To achieve effectively value of VoiSS into two groups: Vocally Healthy Group and their communicative results, vocal professionals are exposed Vocal Risk Group. The latter presented a worse VTDS score after to vocal effort, making them susceptible to the development the teaching activity. The VTDS is a short and rapid question- of vocal pathologies.1 Voice disorders in vocal professionals naire, which could allow the early identification of voice (occupational dysphonia) are part of dysfunctional dyspho- disorder in teachers and could improve the compliance of nia, caused by an incorrect production of the vocal signal teachers with preventive activities. For the first time in the (Malmenage) or an excessively prolonged use of the voice literature, we aimed to check the correlation between the (Surmenage).2 Vocal Tract Discomfort Scale (VTDS) with the Voice Symptom Teachers showed the highest risk to develop voice disor- Scale (VoiSS), so as to demonstrate their combined use to ders: they are subject to prolonged vocal effort, often in a work improve the early detection of vocal disorders in Italian environment characterized by a high background noise and teachers without previous diagnosis. In addition, we aimed unfavorable acoustic conditions.3 Furthermore they may have to investigate whether there are differences in the frequency inadequate postures, usually do not know the vocal hygiene and intensity of discomfort symptoms in teachers with dis- standards and can deal with anxiety and stress situations.1 abilities comparing vocal tract discomfort symptoms in teach- Studies reveal that 20% of teachers are subject to pro- ers with high risk (HRVD) and low risk (LRVD) of vocal longed vocal effort. The prevalence of dysphonia is higher in disorders according to the VoiSS cutoff (> 15.5). teachers (11%) than in other professional categories (6.2%),4 the prevalence for teachers at a single point in time ranged Methods from 9 to 37%,5 the lifetime prevalence of voice disorders (teachers affected by dysphonia at some point in their A retrospective, descriptive and cross-sectional study was lifetime) ranged from 50 to 80%.5,6 performed in our Department of Otorhinolaryngology from Vocal disorders can impact differently according to the 2017 to 2018 and was approved by the Ethics and Research profession: for vocal professionals, such as singers, actors, Committee of our institution under the report number 1.202. radio and TV hosts, teachers, lawyers, dysphonia has a higher After contacting school principals who promoted the possi- effect on quality of life. In fact they are often the cause of bility of participating in the project among dependent teachers, social isolation and absence from work due to illness and a total of 198 teachers have decided to join the initiative and patients underestimate the problem without wishing to signed an informed consent form about the realization of the undergo phonic examination with a fiber optic laryngoscope. study. These teachers were asked to complete the question- Through self-assessment tools, it is possible to know the naires at school before starting work to avoid bias related to sensations of the patient due to the vocal disorder, the stress and fatigue due to sustained lessons. awareness of dysphonia, and the impact of dysphonia on The inclusion criteria comprised teachers > 25 and < 65 quality of life.7,8 The Vocal Tract Discomfort Scale (VTDS) is years old, with a workload of 36 hours a week, with at least a self-assessed questionnaire for the subjective evaluation 5 years of service, and completion of the 2 protocols for self- of voice disorders, proposed by Mathieson in 1993, com- assessment (VoiSS and VTDS). monly used in Great Britain.9 It measures the perception of The exclusion criteria were as follows: teachers who were discomfort in the vocal tract using eight qualitative descrip- on vacation, medical leave, or absent from teaching, who had tors according to the frequency and intensity of symptoms previously undergone surgical or speech-language therapy, on a numerical scale from 0 to 6.10 The subject attributes a and who presented neurological, psychological and/or psy- score that best represents the frequency and intensity of chiatric alterations and who were diagnosed with vocal each symptom: burning in the throat, throat tightness, dry disorders on an organic basis by an otorhinolaryngologist; throat, sore throat, itchy throat, sensitive throat, throat hormonal problems, use of medication, and smoking were irritation and lump in the throat. Therefore, the question- disregarded11–14. These exclusion criteria were chosen to naire contains all of the symptoms that the vocal profes- evaluate the effectiveness of the questionnaires in identify- sionals underestimate and that are represented in cases of ing teachers who do not have vocal diseases in place but are vocal disorders. at professional risk for these disorders. The Voice Symptom Scale (VoiSS) is a multidimensional Considering these criteria, the study sample was com- questionnaire, divided into three scales (physical symptoms, posed of 160 Italian teachers, of which 111 (69.37%) were vocal impairment, emotional impact), which investigates the women and 49 (30.62%) were men, with a mean age of 50.05 frequency of occurrence of communication difficulties, vocal (8.26 standard deviation [SD]) years old and a mean 20.78 symptoms, stress and emotional impact of the voice disorder (9.57 SD) years of service. Of these teachers, 6 (3.75%) were on the life of the patients1,7. The subject indicates the of nursery school, 28 (17.5%) of primary school, 68 (42.5%) of frequency with which he or she is affected by vocal symp- lower secondary school/junior high school, and 58 (36.25%) toms.7 This questionnaire is already validated and used in of high school. Each teacher underwent a brief anamnesis Italy. (gender, age, kind of school, years of service) and completed International Archives of Otorhinolaryngology Vol. 24 No. 3/2020 Vocal Tract Discomfort Scale (VTDS) and Voice Symptom Scale (VoiSS) Galletti et al. 325 the vocal self-assessment protocols (VoiSS and VTDS), both symptoms of discomfort between the HRVD and LRVD groups. cross-culturally adapted into Italian.8,15 The groups were created using the cutoff values of the different The VTDS15–17 assesses the frequency and intensity of domains of the VoiSS (total, limitation domain, emotional symptoms of discomfort of the vocal tract. It comprises eight domain, and physical domain). This test was designed to detect qualitative patient-derived symptoms or sensations common- whether HRVD teachers would present a higher number, and ly referred to the vocal tract (burning, tight, dry, aching, greater frequency and intensity of vocal tract discomfort tickling, sore, irritable, and lump in the throat). Each item is symptoms, as detected by the VTDS. A p  0.05 was considered rated on a 7-point Likert scale (from 0  6), both for its significant. frequency (from “never” to “always”) and its severity (from “none” to “extreme”). The total VTDS score ranges from 0  96, Result whereas the score for each subscale ranges from 0  48. The following cutoff values were used, according to the Our study evidenced a statistically significant correlation literature,18 to indicate the presence or not of symptoms: (p < 0.05) between number, intensity and frequency of VTDS > 0.5 for burning, tightness, aching, tickling, and soreness, and the total and subscales of VoiSS. The number of symp- and > 2.5 for dryness, irritation, and having a lump in the toms of discomfort showed a moderate correlation when throat. compared with the total score, the limitation domain score, The VoiSS19 investigated the frequency of occurrence of and the physical domain score (p < 0.001) of the VoiSS. Only vocal symptoms. It includes 30 items, of which 15 are on the the emotional domain score of the VoiSS showed a weak limitation domain (VOISS-L), 8 are on the emotional domain positive correlation (p < 0.001). (VOISS-E), and 7 are on the physical domain (VOISS-P). Each In particular it was a moderately positive correlation item, according to the Likert scale, scored 5 points, numbered between the frequency and intensity of symptoms of dis- from 0 to 4, with a total score ranging from 0  120 (VOISS-T). comfort of the vocal tract and the total score of the VoiSS The scores for the items in each domain were summed. The overall about intensity and frequency of soreness. Similary, cutoff values used for the domains for this protocol were as the physical score of the VoiSS evidenced a moderate follows: total ¼ 15.5, limitation domain ¼ 11.5, emotional positive correlation with VDTS, in particular for intensity domain ¼ 1.53, and physical domain ¼ 6.5.8,20 of soreness (Cor ¼ 0.61). Also, the limitation domain of For screening, the cutoff value of the Voice Symptom Scale VoiSS evidenced a moderate correlation with all symptoms (VoiSS)8 was used to divide teachers into two groups: individ- of VTDS, but a weak correlation with aching intensity uals with total VoiSS score  15.5 points were allocated to the (cor ¼ 0.37). A weak correlation was found between the High Risk of Vocal Disorders (HRVD) group (102 teachers), frequency and intensity of symptoms of discomfort of the whereas those with a total VoiSS score < 15.5 points were vocal tract and the emotional score of the VoiSS, except allocated to the Low Risk of Vocal Disorders (LRVD) group (58 frequency of irritability and soreness and intensity of teachers). Both groups were compared to verify a possible soreness (►Table 1). relationship between I-VTDS and total I-VoiSS. The VTDS differed significantly between teachers of the In addition, because we aimed to verify the relationships HRVD and of LRVD groups, with a greater frequency and between each subscale of the two self-assessment instru- intensity of symptoms in the first group. In particular, ments (VTDS and VoiSS), teachers were allocated in two teachers considered as HRVD as detected by the number of subgroups: HRVD and LRVD according to the cutoff values of symptoms, the VoiSS total (►Table 2), limitation (►Table 3), the VoiSS-T scale and of each subscale of the VoiSS. Therefore, emotional (►Table 4) and physical (►Table 5) domain scores we included in the group HRVD only those individuals who showed more symptoms of vocal tract discomfort than presented values above the cutoff point for the total score teachers in the LRVD group (p < 0.001). (VOISS-T) and for the specific subscale (VOISS-E, L, P). The LRVD group included teachers who presented values inferior Discussion to the cutoff point in the total score (VoiSS-T) as well as in the investigated subscale (VOISS-E, L, P). Alterations of the voice are often underestimated in the professional categories at risk. In particular, teachers exposed to vocal abuse present hoarseness, vocal fatigue Data Analysis and burning in the throat. Unfortunately, very often, despite Statistical analyses were performed using IBM SPSS Statistics these symptoms, patients underestimate the possibility of for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). The having a vocal disorder and do not undergo phoniatric data are presented as means with SDs. The Spearman correla- examination. For this reason, the questionnaires can be a tion test was applied to investigate the correlation between the first tool to screen professional categories at risk and direct VTDS and the VoiSS. The correlation coefficient presented a them toward a clinical and instrumental assessment.18 range from  1 to 1 and, according Bartz,21 we classified the Therefore, qualitative and quantitative questionnaires of grade of correlation in: very low (0.1–0.2), low (0.2–0.4), screening must be considered in the early identification of moderate (0.4–0.6), strong (0.6–0.8), and very high (> 0.8). vocal disorders. Ours is the first study aimed to investigate The nonparametric Mann-Whitney U test was used to com- the correlation between the scores of the VoiSS18 and pare the average number, frequency, and intensity of the the VTDS6 in Italian teachers. Moreover, we investigated if International Archives of Otorhinolaryngology Vol. 24 No. 3/2020 326 Vocal Tract Discomfort Scale (VTDS) and Voice Symptom Scale (VoiSS) Galletti et al. Table 1 Correlation Between the Mean, Number, Frequency, and Intensity of Vocal Tract Discomfort Symptoms and the Voice Symptom Scale Scores VOISS-T VOISS-L VOISS-E VOISS-P Variables Corr p-value Corr p-value Corr p-value Corr p-value Number of VTDS 0.52 < 0.001 0.45 < 0.001 0.30 < 0.001 0.62 < 0.001 Fr. Burning 0.51 < 0.001 0.47 < 0.001 0.25 < 0.001 0.51 < 0.001 Fr. Tightness 0.57 < 0.001 0.52 < 0.001 0.36 < 0.001 0.53 < 0.001 Fr. Dryness 0.48 < 0.001 0.45 < 0.001 0.31 < 0.001 0.41 < 0.001 Fr. Aching 0.53 < 0.001 0.42 < 0.001 0.40 < 0.001 0.57 < 0.001 Fr. Tickling 0.48 < 0.001 0.42 < 0.001 0.31 < 0.001 0.47 < 0.001 Fr. Soreness 0.61 < 0.001 0.53 < 0.001 0.46 < 0.001 0.57 < 0.001 Fr. irritability 0.56 < 0.001 0.49 < 0.001 0.43 < 0.001 0.50 < 0.001 Fr. lump in the throat 0.52 < 0.001 0.43 < 0.001 0.39 < 0.001 0.53 < 0.001 Int. Burning 0.48 < 0.001 0.42 < 0.001 0.31 < 0.001 0.52 < 0.001 Int. Tightness 0.58 < 0.001 0.53 < 0.001 0.37 < 0.001 0.54 < 0.001 Int. Dryness 0.51 < 0.001 0.46 < 0.001 0.31 < 0.001 0.43 < 0.001 Int. Aching 0.49 < 0.001 0.37 < 0.001 0.38 < 0.001 0.59 < 0.001 Int. Tickling 0.48 < 0.001 0.41 < 0.001 0.31 < 0.001 0.46 < 0.001 Int. Soreness 0.63 < 0.001 0.54 < 0.001 0.48 < 0.001 0.61 < 0.001 Int. irritability 0.53 < 0.001 0.47 < 0.001 0.38 < 0.001 0.48 < 0.001 Int. lump in the throat 0.52 < 0.001 0.43 < 0.001 0.39 < 0.001 0.55 < 0.001 Abbreviations: Corr., correlation; E, emotional; Fr., frequency; Int., intensity; L, limitation; P, physical; T, total; VoiSS, Voice Symptom Scale; VTDS, Vocal Tract Discomfort Scale. Table 2 Comparison of the Mean, Number, Frequency, and Intensity of Vocal Tract Discomfort Symptoms in teachers with high risk (HRVD) and low risk (LRVD) of vocal disorders according to the Total Score of VoiSS VOISS-T HRVD LRVD Variables M SD M SD p-value Number of VTDS 2.33 1.15 1.20 1.03 < 0.001 Fr. burning 2.92 1.30 1.77 1.49 < 0.001 Fr. tightness 2.11 1.45 0.86 1.08 < 0.001 Fr. dryness 2.90 1.33 1.39 1.34 < 0.001 Fr. aching 2.35 1.28 1.20 1.07 < 0.001 Fr. tickling 2.50 1.69 1.20 1.37 < 0.001 Fr. soreness 2.93 1.51 1.25 1.29 < 0.001 Fr. irritability 2.77 1.50 1.22 1.18 < 0.001 Fr. lump in the 1.6 1.67 0.48 1.03 < 0.001 throat Int. Burning 2.82 1.28 1.68 1.36 < 0.001 Int. tightness 2.10 1.34 0.84 1.03 < 0.001 Int. dryness 2.87 1.39 1.34 1.25 < 0.001 Int. aching 2.48 1.36 1.34 1.20 < 0.001 Int. tickling 2.5 1.75 1.17 1.41 < 0.001 Int. soreness 2.71 1.39 1.10 1.05 < 0.001 Int. irritability 2.06 1.49 1.20 1.13 < 0.001 Int. lump in the 1.6 1.67 0.39 0.81 < 0.001 throat Abbreviations: Fr., frequency; HRVD, high risk of vocal disorders; Int., intensity; LRVD, low risk of vocal disorders; SD, standard deviation; T, total; VoiSS, Voice Symptom Scale; VTDS, Vocal Tract Discomfort Scale. International Archives of Otorhinolaryngology Vol. 24 No. 3/2020 Vocal Tract Discomfort Scale (VTDS) and Voice Symptom Scale (VoiSS) Galletti et al. 327 Table 3 Comparison of the Mean, Number, Frequency, and Table 4 Comparison of the Mean, Number, Frequency, and Intensity of Vocal Tract Discomfort Symptoms in teachers with Intensity of Vocal Tract Discomfort Symptoms in teachers with high risk (HRVD) and low risk (LRVD) of vocal disorders according high risk (HRVD) and low risk (LRVD) of vocal disorders according to the limitation Score of VoiSS to the emotional Score of VoiSS VOISS-L VOISS-E HRVD LRVD HRVD LRVD Variables M SD M SD p-value Variables M SD M SD p-value Number of VTDS 2.83 1.29 1.35 1.05 < 0.001 Number of VTDS 3.01 1.36 1.15 1.08 < 0.001 Fr. burning 3.10 1.33 1.77 1.49 < 0.001 Fr. Burning 3.03 1.25 1.73 1.48 < 0.001 Fr. tightness 2.33 1.45 0.86 1.08 < 0.001 Fr. Tightness 2.41 1.48 0.84 1.08 < 0.001 Fr. dryness 2.88 1.29 1.39 1.34 < 0.001 Fr. Dryness 3.05 1.41 1.38 1.35 < 0.001 Fr. aching 2.44 1.33 1.20 1.07 < 0.001 Fr. Aching 2.67 1.22 1.17 1.05 < 0.001 Fr. tickling 2.64 1.63 1.20 1.37 < 0.001 Fr. tickling 2.77 1.81 1.14 1.28 < 0.001 Fr. soreness 2.79 1.44 1.25 1.29 < 0.001 Fr. Soreness 3.41 1.47 1.19 1.20 < 0.001 Fr. irritability 2.79 1.47 1.22 1.18 < 0.001 Fr. Irritability 3.10 1.59 1.23 1.19 < 0.001 Fr. lump in 1.83 1.66 0.48 1.03 < 0.001 Fr. lump in 2.02 1.70 0.47 1.03 < 0.001 the throat the throat Int. Burning 2.90 1.27 1.68 1.36 < 0.001 Int. Burning 3.07 1.23 1.64 1.34 < 0.001 Int. tightness 2.36 1.25 0.84 1.03 < 0.001 Int. Tightness 2.56 1.15 0.82 1.03 < 0.001 Int. dryness 2.92 1.40 1.34 1.25 < 0.001 Int. Dryness 3.05 1.52 1.33 1.25 < 0.001 Int. aching 2.53 1.42 1.34 1.20 < 0.001 Int. Aching 2.77 1.21 1.31 1.19 < 0.001 Int. tickling 2.65 1.69 1.17 1.41 < 0.001 Int. Tickling 2.75 1.90 1.10 1.33 < 0.001 Int. soreness 2.80 1.44 1.10 1.05 < 0.001 Int. Soreness 3.12 1.42 1.05 0.98 < 0.001 Int. irritability 2.67 1.49 1.20 1.13 < 0.001 Int. Irritability 2.86 1.61 1.21 1.14 < 0.001 Int. lump in 1.81 1.64 0.39 0.81 < 0.001 Int. lump in 2.05 1.77 0.38 0.81 < 0.001 the throat the throat Abbreviations: Fr., frequency; HRVD, high risk of vocal disorders; Int., Abbreviations: E, emotional; Fr., frequency; HRVD, high risk of vocal intensity; L, limitation; LRVD, low risk of vocal disorders; SD, standard disorders; Int., intensity; LRVD, low risk of vocal disorders; SD, standard deviation; VoiSS, Voice Symptom Scale; VTDS, Vocal Tract Discomfort deviation; VoiSS, Voice Symptom Scale; VTDS, Vocal Tract Discomfort Scale. Scale. those professionals considered at high risk of voice problems, positive correlation between the scores of VTDS and scores as detected by the VoiSS, have a higher number and a greater of the functional and emotional domains of the VHI. frequency and intensity of vocal tract discomfort symptoms Although the VHI, like the VoiSS, incorporates the psychoso- than teachers with a lower risk of voice problems. Previously, cial impact of a dysphonia,23 only the VoiSS includes physical in a case-control study, Lira Luce et al selected a sample of symptoms and shares therefore a major specificity with the 157 Italian teachers that were examined through a question- VTDS in examining the frequency of voice symptoms.7 naire with clinical data, the Italian validated translation of Moreover, our sample showed a moderate positive correla- the voice handicap index (VHI), a laryngostroboscopic exam tion between the VTDS and the total score of the VoiSS, and logopedic evaluation.22 The VHI score was higher in whereas it showed a weak correlation if we considered the teachers with laryngostroboscopic disorders than in the E-VoiSS. These data may indicate that the self-perception of other subgroup (18.35  13.8 versus 13.45  11.46; Mann- the voice disorder in different aspects of the emotional life of Whitney test, p ¼ 0.026). Although these authors used a the patients is changeable. In fact, several studies showed different questionnaire, they confirmed that the VHI score that the emotional impact of a voice disorder is particularly anticipates the results obtained by confirmation laryngos- influenced by each cultural and psychosocial state,25 not troboscopy. We preferred the VoiSS related to VTDS because correlated with the presence of physical symptoms. Rather, it is psychometrically considered the most robust and not always negative feelings derive from vocal disorders but, extensively validated self reported voice measure avail- on the contrary, in a bidirectional relationship, emotional able.23 Furthermore, in a sample of polish teachers, Niebu- features may cause secondary dysphonia.26 Thus, from the dek-Bogusz et al24 evidenced a strong positive correlation previously published findings and those of our study, it is between the scores of the VTDS and the total scores and the clear that vocal tract discomfort symptoms can impact scores of physical domain of the VHI, and a moderately emotions, although there is not a strong linear relationship International Archives of Otorhinolaryngology Vol. 24 No. 3/2020 328 Vocal Tract Discomfort Scale (VTDS) and Voice Symptom Scale (VoiSS) Galletti et al. Table 5 Comparison of the Mean, Number, Frequency, and for the identification of a population that is at risk.28 The Intensity of Vocal Tract Discomfort Symptoms in teachers with same auditory-perceptual evaluation, acoustic analysis, high risk (HRVD) and low risk (LRVD) of vocal disorders according aerodynamics evaluation, and endoscopic larynx examina- to the physical Score of VoiSS tion did not detect these pharyngeal disorders in dysphonic patients and, therefore, the VTDS showed an advantage in VOISS-P this sense. Thus, the VTDS appears to provide important HRVD LRVD information that complements other instruments in the Variables M SD M SD p-value context of vocal evaluations. Obviously, the questionnaires represent screening tools to identify risk categories and, Number of VTDS 2.97 1.36 1.35 1.01 < 0.001 therefore, require a subsequent diagnostic confirmation Fr. burning 3.17 1.25 1.77 1.49 < 0.001 through phoniatric examination. Fr. tightness 2.38 1.45 0.86 1.08 < 0.001 Fr. dryness 2.92 1.30 1.39 1.34 < 0.001 Conclusion Fr. aching 2.66 1.28 1.20 1.07 < 0.001 The current Italian law does not include any guidance Fr. tickling 2.72 1.85 1.20 1.37 < 0.001 regarding voice education, prevention of voice disorders Fr. soreness 3.24 1.51 1.25 1.29 < 0.001 and screening in subjects with high vocal loading, such as Fr. irritability 2.91 1.53 1.22 1.18 < 0.001 teachers. Our study showed a weak to moderate positive correlation between the VTDS and the VoiSS results. Patients Fr. lump in 1.93 1.76 0.48 1.03 < 0.001 the throat with a high risk of voice disorders detected by the cutoff values of the VoiSS have VTDS scores indicating a higher Int. burning 3.14 1.27 1.68 1.36 < 0.001 number, and greater frequency and intensity of vocal tract Int. tightness 2.66 1.13 0.84 1.03 < 0.001 discomfort symptoms than teachers with LRVD. These Int. dryness 2.92 1.38 1.34 1.25 < 0.001 results suggest that both questionnaires could be useful for Int. aching 2.79 1.36 1.34 1.20 < 0.001 a preventive voice program for the Italian teachers for the early identification of risk categories for voice disorder. Int. tickling 2.66 1.88 1.17 1.41 < 0.001 Int. soreness 3.02 1.43 1.10 1.05 < 0.001 Conflict of Interests Int. irritability 2.76 1.63 1.20 1.13 < 0.001 The authors have no conflict of interests to declare. Int. lump in 1.97 1.76 0.39 0.81 < 0.001 the throat References Abbreviations: Fr., frequency; HRVD, high risk of vocal disorders; Int., 1 Amaral AC, Zambon F, Moreti F, Behlau M. Vocal tract discomfort in intensity; LRVD, low risk of vocal disorders; P, Physical; SD, standard teachers after teaching activity. CoDAS 2017;29(02):e20160045 deviation; VoiSS, Voice Symptom Scale; VTDS, Vocal Tract Discomfort Scale. 2 Rosen CA, Murry T. Nomenclature of voice disorders and vocal pathology. 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