INFLUENCE OF GENDER , AGE , OCCUPATION AND PHONOAUDIOLOGICAL DIAGNOSIS IN THE VOICE QUALITY OF LIFE Influência do sexo , idade , profissão e diagnóstico fonoaudiológico na qualidade de vida em voz

(1) Universidade Federal de Santa Maria – UFSM, Santa Maria, RS, Brasil. Funding: CNPq; CAPES Conflict of interest: non-existent A restriction on communication may be characterized by the loss or reduction of ability to interact vocally and limitation on quality of life, on voice related aspects, may be defined as a self-perceived decrease on the physical, emotional, social or economic status of the person due to dysfunction vocal3. These definitions highlight the fact that a voice problem affects individuals differently. To an evaluation on the impact of a voice disorder, the laryngoscopic findings, the description of vocal deviations and acoustic characterization are not sufficient, because it lacks important information about how this change interferes on daily activities in personal, social and occupational context4.  INTRODUCTION


INTRODUCTION
The voice is present in the processes of human socialization as a component of oral communication and interpersonal relationship, so that vocal changes may produce impacts on people's quality of life in general, but also in occupations who rely on voice production and/or specific vocal quality for their survival occupation 1,2 .
The target population consisted of patient records contained in the database of the voice department of a clinical-school of Speech Language Pathology from October, 2009, year in which the questionnaires on quality of life began to be applied in this sector, to July, 2012.
The inclusion criteria for the selection of database records were: registration of phonoaudiological diagnosis, gender, age, occupation and complete responses to the questionnaires V-RQOL and VHI.The exclusion criteria was incomplete records.
After applying the inclusion and exclusion criteria, the sample consisted of 48 records of patients aged between 18 and 63 years (mean 24:01).
From this sample, were surveyed and analyzed phonoaudiological diagnosis, classifying it in Functional Dysphonia (FD) -arising from own use of voice, without the presence of structural vocal fold lesions, Organic Dysphonia (OD) -independent of the use of voice, Organic-functional Dysphonia (OFD) -the presence of lesions resulting from use of voice 1 ; gender (male or female); classification of people according to age, in adolescents (13-18 years-old), adult (19-44 years-old) or middle-aged (45-64 years-old)(DeCS, 2013); occupational or non occupational use of voice (the occupational depends on specific vocal quality production and/ or quality to their occupational survival, belonging to this group singers, teachers, lawyers, religious, actors, salesmen, telemarketers, stock exchange operators, among others 1 ), as well as the answers to questionnaires V-RQOL and VHI.
For the analyzed variables, the sample was characterized by: 41 subjects were female and 7 male; 8 teenagers, 36 adults and 4 middle-aged; 6 occupational voice users and 42 non occupational voice users, 39 subjects with phonoaudiological diagnosed FD (absence of laryngeal disease or presence of postural changes of vocal folds), 6 subjects with OD (association with inflammatory and infectious diseases) and 3 OFD (presence of edema or nodules).
The V-RQOL protocol includes ten questions involving aspects of the uses of the voice and their impact on quality of life.Responses should be marked on a scale of one to five, taking into consideration the severity of the problem and its frequency of appearance.The questions of V-RQOL are divided into three domains: social-emotional, physical and global (encompassing the first two domains).The maximum value is 100 (indicating better results, with less voice negative impact on quality of life) and the minimum is zero 6 .
The World Health Organization, after consensus among experts, defined quality of life as the individual's perception about his condition of life in the cultural context and values and about the relation with expectations, objectives and standard concerns 5 .Thus, it is considered quality of life as the integrity of multidimensional factors based on physical, mental and social parameters 2 .
The evaluation of the relation between voice and quality of life is basically done through questionnaires.The American questionnaire Voice Related Quality of Life (V-RQOL) 6 was translated and adapted to Brazilian reality as Questionário de Qualidade de Vida em Voz (QVV) 7 , used to measure the impact of dysphonia in quality of life.The questionnaire Vocal Handicap Index (VHI) 8 was translated and validated in Brazil as Índice de Desvantagem Vocal (IDV) 9 and is designed to detect psychosocial consequences generated by the vocal quality disturbance 8 .
Recently, the results of self-assessment protocols of treatment used in dysphonic populations were reviewed to understand if the procedures used beheld the standards of content development and psychometric assessment, concluding that none of the quality of life protocols currently used in the area of voice includes the essential methodological criteria for its elaboration 10 .
However, despite the restrictions presented by questionnaires 10 , it is believed that the use of such instruments allow the observation of a progression on a dysphonia, the effectiveness of phonoaudiological therapy, and allows making therapeutic decisions based in the self-perception of the person about his voice and limitations in the quality of life reported.
In this context, there are scientific studies in the literature addressing the effects of voice disorders on quality of life in different populations 4,6,[9][10][11][12][13][14] .However , there are few studies correlating the variables addressed in this study (age, gender and occupational use or non occupational use of voice) with the results of the questionnaires V-RQOL and VHI 15 , and so far none of them correlated phonoaudiological diagnosis with the same questionnaires.
Thus, this research aims to investigate and correlate the responses to the questionnaires Voice Related Quality of Life (V-RQOL) and Voice Handicap Index (VHI) in a group of subjects according to age, gender, occupational or non occupational use of voice and phonoaudiological diagnosis.

METHODS
Analytical, quantitative and retrospective observational cross sectional study, approved by the between the protocols V-RQOL and VHI), both with a significance level of 5% ( p<0.05).

RESULTS
Table 1 shows the correlation of the emotional, physical and total V-RQOL and emotional, functional, physical and total VHI with male and female scores.It was observed a statistically significant association between female and emotional V-RQOL score (p=0.0165) and between male and emotional VHI score (p=0.0406).
VHI protocol produces four scores, one of full disadvantage and three of sub-scales "E" (emotional), "F" (functional) and "O" (organic).The maximum score for each sub-scale is 40 points and the calculation of the total score is done by simple addition, with a maximum disadvantage of 120 points.As higher the score in this protocol is, the greater the perceived disadvantage by subject is 8 .
For statistical analysis, chi-square tests were used (to analyze the correlation of V-RQOL and VHI protocols with the variables gender, age, occupation and phonoaudiological diagnosis) and Spearman's correlation coefficient (for analyzing the correlation

Male (n=7) p-value
Table 2 shows the correlation of scores V-RQOL and VHI with teenage, adult and middle-aged ages.A statistically significant association between age and emotional V-QROL score was observed (p=0.0028),where the middle-aged had lower scores, and between age and emotional score (p=0.0145) and physical (p=0.0347) of IDV, where middle-aged had higher scores.between non occupational use of voice and total score (p=0.0055),emotional (p=0.0400) and physical (p=0.0395) of V-QROL, and between occupational use of voice and functional score (p=0.0088) of VHI.
Table 5 shows the negative correlation between emotional, physical and total scores of V-QROL and emotional, functional, physical and total scores of VHI.
Table 3 shows the correlation of scores V-RQOL and VHI with the phonoaudiological diagnosis of FD, FO and OFD.It was observed a statistically significant association between phonoaudiological diagnosis and VHI emotional score (p=0.0008), with the diagnosis of OFD with higher scores.
Table 4 shows the correlation of scores V-RQOL and VHI with the occupational and non occupational use of voice.A statistically significant association  phonoaudiological therapy in the clinic of voice than men 15 , which was also observed in this work where most of the records of the school clinic were women.
The greatest emotional impact on men suggests greater concern about the quality of the voice regarding to the impression on listeners, so that the change can provide discomfort and/or embarrassment through interpersonal relationships.Probably, voice changes in women are more accepted by listeners than in men, making women do not bother much about the perception caused by their voices.
In the present study, age influenced the value of the emotional score V-RQOL, beyond the physical and emotional of VHI, where older individuals had the lowest score of the emotional V-RQOL, as well as higher values in the physical and emotional scores of VHI.
According to the literature, the age variable deserves attention, because as age advance, the vocal efficiency decreases, with greater or lesser vocal impact 13 , and a positive correlation was found between the total score of VHI and age 19 .Other studies have also found that elderly showed lower scores of V-RQOL compared to younger individuals, realizing greater impact of dysphony on their quality of life 23,24 .
These results can be justified by the fact that, with aging, changes in laryngeal structures and consequent vocal changes happen, which influence the process of construction of personal identity and may be a factor of conflict, interfering in quality of life 1,25,26 , since the voice has specific characteristics in adolescence, adulthood and senescence.However, there are studies in the elderly in whom there was no difference about the age in the scores of V-RQOL protocol 16,24,27 .
There was also a correlation between the phonoaudiological diagnosis and the emotional

DISCUSSION
The VHI and V-RQOL protocols have been used in investigations that are guided by the vocal self-assessment and the perceptions of individuals about their own voice and their voice disorders.Such instruments intended to explore the impact of voice disorders on patient's quality of life in clinical voice and also in people who use the voice professionally, and other social levels.It is about functionally simple protocols, easy to apply, which have clear questions, thus becoming clinical tools for the assessment of treatment results.Also, provide more refined understanding of the dimensions of the effects of a voice problem in the patient's life and their psychosocial consequences, through selfawareness about their dysphonia, despite criticism on its preparation 1,4,9,[11][12][13][14][15][16][17][18][19] .
In the present study, the studied group was characterized by a predominance of females, adult, no professional use of voice and individuals with FD, agreeing with other current studies found in the literature 13,14 .
Gender showed a significant association with emotional scores of VHI and V-RQOL, with the average of the emotional scores of V-RQOL higher in women and lower in VHI, when compared with men.Thus, it appears that the emotional impact was greater in males, so that results in the two protocols were similar.This finding agrees with two studies that compared gender with VHI protocol and did not observed significant differences 19,20 .

Spearman correlation
*statistically significant values: p <0,05 dysphonia, suggesting that dysphonia compromises the quality of life in a similar way in both groups 2 .These findings can be explained by the fact that professional use of voice possibly resorting to specialized help early, so that the problem does not harm the career or their social life.
Even, in this investigation, there was a significant negative correlation between all V-RQOL scores and among all VHI scores, showing that the protocols are complementary, showing that, when the V-RQOL scores increase, VHI scores decrease and vice-versa, assessing the impact of voice on people's quality of life.In other research 28 , it was found that the VHI and V-RQOL protocols are complementary, but not entirely interchangeable, as there were no negatively correlation, disagreeing to the present work.
However, a literature review article states that none of the quality of life instruments currently used in voice area covers all essential criteria for its development, also pointing out deficiencies in both protocols used in this work 10 .
Recent study correlated voice quality with the responses to V-RQOL in a group of 73 teachers and found no association between changes in vocal quality and responses to V-RQOL.However, it was observed that the areas of V-RQOL showed significant correlations between themselves 13 .
Another study found that the V-RQOL physical score matches to the organic VHI and that subjects with laryngeal disorders had V-RQOL physical score decreased and VHI organic score increased 28 .
Based on the results of this research, it can be inferred that the self-assessment of quality of life and disadvantage related to voice is an important aid to understanding the perception of people regarding to their vocal health and their reactions to voice changes 12,15 .
To a better understanding of the role of such protocols, more studies are needed.However, based on the results obtained and the existing literature on the subject, it is possible to affirm that such protocols seem to complement each other, show feasible relations with variables such as age, gender, occupation and types of dysphonia, and are useful in the evidence for the subjective aspects of the patient's perception of its evolution in the treatment itself.
The findings on this study help to understand the possible impact of age, occupation, gender and phonoaudiological diagnosis on quality of life and the self-assessment disadvantages regarding to voice and also are useful to affirm the importance of using self-assessment protocols, such as VHI and V-RQOL, in the phonoaudiological clinical practice.score values of VHI, showing that subjects with OFD got higher values, in other words, greater negative impact when compared with diagnoses of functional and organic dysphonia.Studies indicate that laryngeal disorders cause negative impact on people's quality of life 2,12,25,28 because undertake communication and, consequently, people social relations.However, in a research which related quality of life and voice to the degree of dysphonia, no significant difference was found 2 , and in another study, with people who underwent cordectomy, with OD, it was found no reduction in scores of V-RQOL 11 .
In this investigation, the presence of OFD caused higher voice handicap, especially in the emotional aspect, showing that the occurrence of vocal fold lesions resulting from functional dysphonia diagnosed late, and thus, related to the use of voice, interfered on activities of daily life, causing limitations in social or personal life 1,29 .
Even, in another study, subjects with spasmodic dysphonia had higher scores in VHI, showing a reduction of these scores after neurectomy of the thyroarytenoid branch of the inferior laryngeal surgery, showing that the presence of any lesion, regardless of its cause, affects quality of life 30 .
In this study, the occupation has influenced the values of all V-RQOL scores and functional VHI score, and no professionals of voice had the highest physical and emotional V-RQOL scores, as occupational voice users had higher scores on functional VHI, showing greater voice handicap.
Professional voice users feel more the impact of dysphonia, because they depend on a production and specific vocal quality to their occupational survival, and have great vocal demand, justifying the increase in functional VHI score as well as the best quality of life of non voice occupational found 29 .
Confirming these results, a study that verified the impact of dysphonia in dysphonic teachers showed poorer quality of life in V-RQOL compared to the general population of dysphonics 8 .The physical domains of V-RQOL and organic of VHI showed similar results, however, the socio-emotional of V-RQOL showed greater impact on voice changes in dysphonic teachers than the VHI.
Another study that verified self-reported impact of voice disorders on people quality of life with vocal complaints, also used V-RQOL protocol and found that in the occupational voice level I (actors and singers) showed the highest levels in total and physical 15 .
However, research that used V-RQOL protocol and aimed to relate the quality of life and voice with degree of dysphonia and professional use of voice found no significant difference between occupational and non occupational about the degree of organic-functional dysphonia generated greater voice handicap and professional use of voice presented worse quality of life.The VHI and V-QROL protocols showed complementary and useful results to measure the impact of voice on people's quality of life.

Table 2 -Correlation of scores questionnaires Voice Related Quality of Life and Voice Handicap Index with age
Qui-quadrado test * statistically significant values: p <0,05