10.14639/0392-100X-N2018
Objective. Considering the impact of dysphonia on public health and the increasing attention to patient-centred care, we evaluated sex-related differences in the prevalence of benign voice disorders, awareness of dysphonia and voice therapy (VT) results. Methods. One hundred and seventy-one patients, 129 females and 42 males, with functional or organic benign dysphonia underwent Voice Handicap Index (VHI), auditory-perceptual dysphonia severity scoring (GRBAS) and acoustic analysis (Jitter%, Shimmer%, NHR) before and after VT. Results. Prevalence of each voice disorder was significantly higher among females. Mean time-to-diagnosis (time elapsed until medical consultation) was not different between males and females. The refusal of therapy and VT adherence (mean number of absences and premature dropout) were similar in the two groups. Pre-VT VHI and “G” parameter were worse in women. The percentage of women with abnormal acoustic analysis was significantly higher. Post-VT VHI gain was higher in women, whereas “G” parameter improvement did not differ by sex. Conclusions. Our study showed a higher prevalence of voice disorders in females. Awareness of dysphonia was not gender related. Females started with worse voice subjective perception and acoustic analysis, but they perceived greater improvement after therapy.
text/xml
1827-675X
2018
en
Lucia D'Alatri
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
acoustic analysis
Gender-related differences in the prevalence of voice disorders and awareness of dysphonia
Text.Serial.Journal
https://www.actaitalica.it/
42
Audiology
2022-11-23
2022-01-24
2022-12-13
2022-12-13
458-464
1
Lucia D'Alatri
2022/11/23
10.14639/0392-100X-N2018
458
Institute of Otolaryngology, Catholic University of the Sacred Heart, Rome, Italy; Department of Aging, Neurological, Orthopedic and Head and Neck Sciences, UOC of Otolaryngology, A. Gemelli IRCCS University Hospital Foundation, Rome, Italy
1827-675X
acoustic analysis
en
464
Gender-related differences in the prevalence of voice disorders and awareness of dysphonia
https://www.actaitalica.it/article/download/2018/872
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:458-464; doi: 10.14639/0392-100X-N2018




Audiology


Gender-related differences in the prevalence of voice
disorders and awareness of dysphonia
Differenze correlate al sesso nella prevalenza delle patologie della voce
e nella consapevolezza della disfonia
Maria Raffaella Marchese1*, Ylenia Longobardi1*, Tiziana Di Cesare1, Giorgia Mari1, Valeria Terruso1, Jacopo Galli1,2,
Lucia D’Alatri1,2
1
  Institute of Otolaryngology, Catholic University of the Sacred Heart, Rome, Italy; 2 Department of Aging, Neurological, Orthopedic
and Head and Neck Sciences, UOC of Otolaryngology, A. Gemelli IRCCS University Hospital Foundation, Rome, Italy
* M.R. Marchese and Y. Longobardi contibuited equally to this work.


SUMMARY
Objective. Considering the impact of dysphonia on public health and the increasing atten-
tion to patient-centred care, we evaluated sex-related differences in the prevalence of benign
voice disorders, awareness of dysphonia and voice therapy (VT) results.
Methods. One hundred and seventy-one patients, 129 females and 42 males, with func-
tional or organic benign dysphonia underwent Voice Handicap Index (VHI), auditory-per-
ceptual dysphonia severity scoring (GRBAS) and acoustic analysis (Jitter%, Shimmer%,
NHR) before and after VT.
Results. Prevalence of each voice disorder was significantly higher among females. Mean
time-to-diagnosis (time elapsed until medical consultation) was not different between
males and females. The refusal of therapy and VT adherence (mean number of absences
and premature dropout) were similar in the two groups. Pre-VT VHI and “G” parameter
were worse in women. The percentage of women with abnormal acoustic analysis was
significantly higher. Post-VT VHI gain was higher in women, whereas “G” parameter im-            Received: January 24, 2022
provement did not differ by sex.                                                                 Accepted: July 30, 2022
Conclusions. Our study showed a higher prevalence of voice disorders in females. Aware-
ness of dysphonia was not gender related. Females started with worse voice subjective            Correspondence
perception and acoustic analysis, but they perceived greater improvement after therapy.          Tiziana Di Cesare
                                                                                                 Department of Head and Neck Sciences, Catho-
KEY WORDS: dysphonia, voice therapy, gender, Voice Handicap Index, acoustic analysis             lic University of Sacred Heart, Policlinico “A.
                                                                                                 Gemelli” Foundation, l.go “A. Gemelli” 8, 00168
RIASSUNTO                                                                                        Rome, Italy
                                                                                                 Tel. +39 06 30154439. Fax +39 06 3051194
Obiettivo. Valutare le differenze legate al sesso nella prevalenza dei disturbi benigni della
                                                                                                 E-mail: tizianadicesare90@gmail.com
voce, nella consapevolezza della disfonia e nei risultati della terapia vocale (TV).
Metodi. 171 pazienti, 129 F e 42 M, con disfonia benigna, funzionale o organica, sono stati
sottoposti a: Voice Handicap Index (VHI), valutazione uditivo-percettiva di gravità della          How to cite this article: Marchese MR, Lon-
                                                                                                   gobardi Y, Di Cesare T, et al. Gender-related
disfonia (GRBAS) e analisi acustica (Jitter%, Shimmer%, NHR) prima e dopo TV.
                                                                                                   differences in the prevalence of voice disor-
Risultati. La prevalenza di ciascun disturbo della voce era significativamente più alta nelle      ders and awareness of dysphonia. Acta Otorhi-
donne. Il tempo atteso per il consulto medico non era diverso tra F e M. Il rifiuto della te-      nolaryngol Ital 2022;42:458-464. https://doi.
rapia, il numero medio di assenze e l’abbandono prematuro erano simili nei due gruppi. Il          org/10.14639/0392-100X-N2018
VHI e il parametro “G” pre-TV erano peggiori nel gruppo F. La percentuale di donne con
analisi acustica anormale era significativamente più alta. Il guadagno di VHI post-TV era        © Società Italiana di Otorinolaringoiatria
maggiore nelle donne, mentre il miglioramento del parametro “G” non differiva in base            e Chirurgia Cervico-Facciale
al sesso.
Conclusioni. Il nostro studio ha mostrato una maggiore prevalenza di disturbi della voce                        OPEN ACCESS

nelle donne. La consapevolezza della disfonia non era correlata al genere. Le donne pre-         This is an open access article distributed in accordance with
sentavano una percezione soggettiva della voce e un’analisi acustica peggiori, ma percepi-       the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                 Commercial-NoDerivatives 4.0 International) license. The
vano un miglioramento maggiore dopo la terapia.                                                  article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: disfonia, terapia vocale, genere, Indice di handicap vocale, analisi              only in the original version. For further information: https://
acustica                                                                                         creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                     Subjective perception of dysphonia and results of voice therapy by gender




Introduction                                                       frequently leads men to undergo specialist examination for
                                                                   dysphonia, while women often present for alterations of the
Excluding the well-known epidemiological discrepancy
                                                                   quality of the voice, breath, or cough 11.
in the distribution of oncological pathologies (e.g., greater      Studies on dysphonia consider sex as a risk factor for the
male predisposition to laryngeal cancer) supported by hab-         development of the disease from a purely epidemiological
its such as smoking and alcohol which are more common              point of view. To date, there are no studies evaluating the
in males, little attention is paid to sex-related differences in   role of gender in the diagnostic or treatment phase of dys-
the management and treatment of voice diseases 1.                  phonia.
Some anatomical and physiological differences of the pho-          Considering the perspective to apply personalised medi-
natory system between the two sexes are widely known,              cine and the increasing attention given to gender-specific
such as the different distribution of hyaluronic acid in the       medicine as a milestone in the progress of patient-centred
vocal folds which in women is not homogeneous, exposing            care, the purpose of this work is to describe sex-related dif-
them more easily to vocal trauma 2. Similarly, a difference        ferences in the prevalence of unilateral vocal fold paralysis
in collagen has been documented in adults, with higher lev-        (UVFP), benign vocal folds lesions and functional dyspho-
els in men 3. Gender differences were also found in phona-         nia, patients’ awareness of dysphonia, voice quality and
tory physiology in terms of subglottic pressure (greater in        outcomes using a multidimensional (subjective, auditory
women) and resistance capacity of the membranous vocal             perceptual and acoustic) voice assessment before and after
fold to phonotrauma (greater in males) 4. The aging pro-           voice therapy (VT).
cess also seems to have a different impact on the larynx of
men and women 5, with a progressive thinning of the vocal
fold mucosa and the superficial layer of the lamina propria,       Materials and methods
an increase in fundamental frequency, a reduction in vocal         We retrospectively collected data on patients affected from
fold contact in men and an opposite trend in women.                dysphonia who referred to the Phoniatric Unit of the “A. Ge-
The gender differences observed in the measurement of              melli” IRCCS University Hospital Foundation of Rome. We
some acoustic parameters, such as Jitter% (more altered            excluded patients with diagnosis of psychogenic dysphonia
in men), Soft Phonation Index (more altered in women),             or previous laryngeal surgery. Patients with a history of psy-
fundamental frequency (naturally more acute in women),             chiatric disorders, depression and use of antidepressant med-
pitch and number of vibratory cycles (higher in women),            ication, patients affected by neurological disorders other than
has led some authors to underline the need to develop dif-         unilateral vocal fold paralysis, especially neurodegenerative
ferent protocols for objective assessment of the voice based       disease as Alzheimer’s and Parkinson’s disease, were also
on gender 6.                                                       excluded. The study sample was selected according to the
It is known that women are more likely to develop a voice          following criteria: age between 18 and 65 years; diagnosis of
disorder than men 7. Women naturally experience several            functional dysphonia (as voice disturbance that occurs in the
periods of hormonal imbalance throughout their lifetime            absence of structural or neurologic laryngeal pathological
that may be related to a higher prevalence of muscle ten-          characteristics) or organic dysphonia caused by iatrogenic
sion dysphonia 8. Receptors for sex hormones have been             unilateral vocal fold paralysis or benign vocal fold lesions
found on vocal folds, suggesting a link between hormone            as Reinke’s oedema, polyp, cyst, or nodules; prescription of
levels and vocal fold function, which might cause changes          voice therapy (VT) as only treatment.
in voice production 9. Banai 10 showed that voices of natu-        Patients underwent a complete multidimensional (subjec-
rally cycling women had higher minimum pitch in the late           tive, auditory perceptual and acoustic) assessment of voice.
follicular phase compared with the other phases. In addi-          This latter included:
tion, voice intensity was at its lowest in the luteal phase.       a) the Italian version of Voice Handicap Index (VHI) 13 to
Psychosocial and socioeconomic characteristics, person-               evaluate patient’s subjective perception of the impact of
ality and behavioural traits, as well as spoiled habits, af-          the dysphonia on the quality of life. It is a questionnaire
fect voice production. Personality traits and temperament             composed of 30 items equally divided between function-
in women, more than in men, can influence the develop-                al, physical and emotional domains, that analyses the bi-
ment of vocal pathologies 11. However, a causal relation-             opsychosocial impact of voice problems. Each question
ship between personality and vocal pathology has not yet              has 5 quantifiable answers (0-4); the final total score (0-
been shown. Furthermore, for women, a certainly higher                120) defines the degree of subjective perception of the
impact of dysphonia on the quality of life has been dem-              voice disorder. VHI was administered before and after
onstrated 12. Pharyngeal globus is the symptom that most              VT;



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M.R. Marchese et al.




b) auditory perceptual evaluation of voice quality carried                     number of subjects with abnormal values of the selected
   out by a single rater (an expert otolaryngologist (DL)                      acoustic parameters before and after VT.
   with more than 10 years of experience in the diagnosis                      Moreover, all cases and each group were divided accord-
   and treatment of voice disorders), blind to the diagno-                     ing to diagnosis into “Unilateral Vocal Fold Paralysis”
   sis, using the Grade-Roughness-Breathiness-Asthenia-                        (UVFP), “Organic Dysphonia” (benign vocal fold lesions
   Strain (GRBAS) scale on recorded voice samples. Voice                       as Reinke’s oedema, polyp, cyst or nodules) and “Func-
   recordings were directly stored in the host computer us-                    tional Dysphonia”. For each type of vocal disorder, data
   ing the Computerized Speech Lab (CSL) Model 4500                            were compared and any differences between group M and
   (Kay Elemetrics, Lincoln Park, NJ). All recordings were                     group F were analysed.
   made in a quiet room (environmental noise < 30 dB                           The data were collected and managed anonymously, and
   SPL). Voice samples consisted of reading the first three                    statistical analysis was performed with the Excel program
   sentences (53 words, 107 syllables) of the passage “Il                      (Microsoft Corporation, Redmond, Washington, USA).
   deserto” (DCA n. U00226, 5 June 2018) at a conversa-                        Continuously distributed data were summarised as mean
   tion loudness level and comfortable pitch. For percep-                      and categorical variables by absolute frequency and per-
   tual assessment only the “G” parameter of the GRBAS                         centages. Differences between the two groups were ana-
   scale was rated since it reflects the severity of dysphonia                 lysed with Student’s test for continuous and normally
   integrating all deviant components. The R, B, A and S                       distributed variables and with Mann-Whitney’s test and
   parameters were not rated because of the wide variabil-                     Fisher’s exact test for categorical variables. For all tests the
   ity of voice features between the subjects included in the                  significance level was set at p < 0.05.
   study. The “G” parameter was measured in each patient
   before and after VT;
c) acoustic analysis routinely carried out with the Mul-                       Results
   tidimensional Voice Program (MDVP) (model 5105)                             One hundred and seventy-one of 212 (85.5%) cases were
   (Kay Elemetrics, Lincoln Park, NJ). We considered jit-                      eligible for our study. Forty-one patients were excluded
   ter percentage (Jitt%), shimmer percentage (Shim%)                          from the analysis due to lack of information in medical re-
   and noise to harmonics ratio (NHR). Our normal val-                         cords. The females (group F) were 129/171 (75.44%) with
   ues were obtained from 100 adult subjects (50 females,                      a mean age of 48 years (range 28-80); the males (group M)
   50 males), euphonic, without any previous vocal pa-                         were 42/171 (24.56%) with a mean age of 54 years (range
   thology, aged between 18 and 70 years. In this norma-                       18-79). For each type of dysphonia, the percentage of fe-
   tive voice parameters vary little according to gender                       males was significantly higher (p < 0.05) confirming the
   (Tab. I).                                                                   higher prevalence of voice disorders in female gender
The acoustic parameters were evaluated before and after                        (Fig. 1). As reported in Figure 1, the prevalence of each
VT on the sustained vowel /a/ produced at a comfortable                        voice disorder was not significantly different between the
pitch and loudness level for at least four seconds.                            two groups (p > 0.05). Within each group (M/F), the preva-
The enrolled subjects were divided in group M (males) and
group F (females). For all the cases and for each group we
analysed: the prevalence of each voice disorder; patients’
awareness of dysphonia by calculating both “time-to-diag-
nosis” (the time interval between the onset of symptoms
and the first medical consultation) and the “VT adherence”
(percentage of refusal of VT, mean number of absences to
the therapy sessions and premature therapy dropout); mean
VHI and “G” parameter improvement after therapy; the


Table I. Normative values of voice parameter for adults (m/f = male/female).
 Voice parameter                             Normal values
 Jitter (M ± SD) m/f                     0.58 ± 0.65/0.63 ± 0.62
 Shimmer (M ± SD) m/f                    3.52 ± 0.60/2.99 ± 0.54
 NHR (M ± SD) m/f                        0.12 ± 0.05/0.11 ± 0.12               Figure 1. Percentage of males and females by each voice disorder.
NHR: noise to harmonics ratio.                                                 UVFP: Unilateral Vocal Fold Paralysis; Tot: Total.



460
                                                                                   Subjective perception of dysphonia and results of voice therapy by gender




                                                                                Table II. Mean pre-therapy and post-therapy VHI scores in each group of
                                                                                subjects and percentage of improvement.
                                                                                                                            VHI score
                                                                                                                    Pre-VT           Post-VT              Gain
                                                                                 Type of dysphonia (N)             M        F       M        F       M           F
                                                                                                                                 Functional score
                                                                                 UVFP                            14.2 19.2* 10.7            5.6      3.5    13.6*
                                                                                 (N 69)
                                                                                 Functional dysphonia             6.9    10.5*      7       7.8     -0.1     2.7
                                                                                 (N 53)
                                                                                 Organic dysphonia                6.3    11.2*     5.8      9.2      0.5         2
                                                                                 (N 49)
                                                                                 Total                           10.1 14.1*        8.3      6.9      1.8     7.2
                                                                                 (N 171)
Figure 2. Percentage of unilateral vocal fold paralysis, functional dysphonia
                                                                                                                                 Emotional score
and organic dysphonia by male and female.
UVFP: Unilateral Vocal Fold Paralysis; Tot: Total.                               UVFP                             7.1    14.4*     4.3      5.8      2.8     8.6
                                                                                 (N 69)
                                                                                 Functional dysphonia             8.3     11.3     5.2      5.3      3.1         6
lence of UVFP, functional dysphonia and the organic ones                         (N 53)
did not significantly differ (p > 0.05). In both groups the                      Organic dysphonia                5.4      8.2     4.5      5.5      0.9     2.7
                                                                                 (N 49)
most frequent diagnosis was the UVFP, followed by func-
                                                                                 Total                            7.1    11.6*     4.6      5.7      2.5     5.9
tional dysphonia and organic dysphonia (Fig. 2).                                 (N 171)
                                                                                                                                  Physical score
Awareness of dysphonia
                                                                                 UVFP                            20.5 25.4* 18.5*           9.9       2     15.5*
The time-to-diagnosis was a mean of 23.6 (range 1-120)                           (N 69)
months, 22.7 months in the group M vs 23.9 months in the                         Functional dysphonia            19.5     19.7     9.5     12.2      10      7.5
group F (p > 0.05). Eighty of 129 (62.01%) females and                           (N 53)
29/42 (69.04%) males consented to undergo VT (p > 0.05).                         Organic dysphonia               13.9 21.2*         14     16.9     -0.1      4.3
A total of 62/171 (36.25%) cases refused, 49/129 (37.98%)                        (N 49)
F vs 13/42 (30.95%) M (p > 0.05). The mean number of                             Total                           18.6 22.3*         15     12.1      3.6    10.2*
therapy sessions was 6.1 (range 4-12) in group M and                             (N 171)
6.1 (range 4-8) in group F (p > 0.05). The number of pa-                                                                           TOTAL score
tients who dropped out therapy (15/80 -18.75% F vs 8/29                          UVFP                            41.9 59.0* 33.6           21.4      8.3     37.6*
- 27.58% M) and the mean number of absences to therapy                           (N 69)
sessions (1.3 F vs 1.5 M) did not significantly differ be-                       Functional dysphonia            34.8     41.6     21.8    25.3      13      16.3
                                                                                 (N 53)
tween the two groups (p > 0.05).
                                                                                 Organic dysphonia               25.6 40.7* 24.3           31.7      1.3         9*
                                                                                 (N 49)
Pre-VT subjective, perceptual and acoustic assessment                            Total                           35.8 47.9* 27.9           24.7      7.9    23.2*
The mean VHI total score and the mean partial scores of each                     (N 171)
domain were significantly higher in the group F (p < 0.05)                      VHI: Voice Handicap Index; VT: Voice Therapy; UVFP: Unilateral Vocal Fold Paralysis;
(Tab. II), especially for the emotional one (11.6 vs 7.1).                      * males vs females: p < 0.05.
Comparing VHI results basing on the aetiology of dyspho-
nia, a significant difference between groups was found for
UVFP and organic voice disorders. Table III shows auditory
                                                                                Post-VT subjective, perceptual and acoustic assessment
perceptual results in each group of subjects. The “G” param-
                                                                                The post-VT VHI total score of group M did not differ
eter of GRBAS score was significantly worse in group F (2.1
vs 1.5) (p < 0.05). The greatest difference between groups                      compared to the one of group F (Tab. II). Moreover, the
was found in subjects affected by organic dysphonia (2.2 F                      post-VT VHI score of each group did not differ based on
vs 1.3 M) (p < 0.05). Moreover, the percentages of patients                     diagnosis except for the UVFP. Males affected by UVFP
with abnormal Jitter% and NHR values in group F were sig-                       scored significantly higher than females in the VHI physi-
nificantly higher than in group M (Tab. IV).                                    cal domain (18.5 vs 9.9) (p < 0.05) (Tab. II).



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M.R. Marchese et al.




Table III. Auditory-perceptual results. The mean scores of the “G” parameter           ly higher in group F (23.2 vs 7.9) (p < 0.05) demonstrating
of GRBAS scale obtained before and after voice therapy (VT) in each group and          a major improvement of subjective perception of the qual-
the gain score.
                                                                                       ity of voice in women than in men after VT. The improve-
                               Score of “G” parameter of GRBAS scale
                                                                                       ment of Physical score was significantly higher in group F
                                      Pre-VT           Post-VT             Gain        (10.2 vs 3.6) (p < 0.05). Post-therapy “G” parameter of the
 Type of dysphonia (N)              M         F       M         F      M          F    GRBAS scale score did not differ between males and fe-
                                                                                       males (Tab. III). The results of acoustic analysis are shown
 UVFP                              2.0      2.3      1.3      1.4      0.7       0.9   in Table IV.
 (N 69)
 Functional dysphonia              1.8      1.9      1.1      1.2      0.8       0.7
 (N 53)                                                                                Discussion
 Organic dysphonia                 1.3      2.2*     0.4      1.5      0.9       0.7
                                                                                       The importance of epidemiologic studies on treatment-
 (N 49)
                                                                                       seeking population with dysphonia to understand its im-
 Total                             1.5      2.1*     0.8      1.4      0.7       0.7
 (N 171)                                                                               pact, evaluation and management is known. Thanks to these
UVFP: Unilateral Vocal Fold Paralysis; *males vs females p < 0.05.                     studies, in fact, we know that functional disorders represent
                                                                                       the most common cause of voice disorders (except in child-
                                                                                       hood) and that “voice professionals” (actors, singers, voice
As shown in Table II, the mean total and sub-total VHI                                 actors, teachers, etc.) represent almost half of the dyspho-
scores decreased after VT in both groups, especially for the                           nic population with a higher prevalence of organic dyspho-
physical domain. The mean total VHI gain was significant-                              nia 14,15. Other frequently detected pathologies are vocal


Table IV. Number and percentage of the cases with abnormal values of the acoustic parameters for each group Pre- and Post-Voice Therapy (VT).
                                                                        Pre-VT                                             Post-VT
 Type of dysphonia (N)                                                 Males               Females                Males                 Females
                                                                                                       Jitter%
 UVFP                                                                   10/12                46/50                  2/9                    4/34
 (N 69)                                                                (52.6%)              (92%)*               (22.2%)                (11.76%)
 Functional dysphonia                                                    6/13                 3/40                  1/5                    0/11
 (N 53)                                                               (46.2%)*              (7.5%)                (20%)                    (0%)
 Organic dysphonia                                                       0/10                20/39                  0/7                    5/20
 (N 49)                                                                  (0%)              (51.3%)*                (0%)                   (25%)
 Total                                                                  16/42               69/129                 3/21                    9/65
 (N 171)                                                               (38.1%)             (53.5%)*              (14.3%)                 (13.8%)
                                                                                                      Shimmer%
 UVFP                                                                   19/19                 47/50                 2/9                   6/34
 (N 69)                                                                (100%)                 (94%)               (22.2%)               (17.6%)
 Functional dysphonia                                                   13/13                 20/40                 1/5                   0/11
 (N 53)                                                               (100%)*                 (50%)                (20%)                  (0%)
 Organic dysphonia                                                      10/10                 21/39                 4/7                  10/20
 (N 49)                                                               (100%)*               (53.8%)              (57.14%)                (50%)
 Total                                                                  42/42                88/129                 8/2                  16/65
 (N 171)                                                              (100%)*               (68.2%)               (38.0%)               (24,6%)
                                                                                                        NHR
 UVFP                                                                  0/19                   11/50                0/9                    0/34
 (N 69)                                                                (0%)                  (22%)*               (0%)                    (0%)
 Functional dysphonia                                                  0/13                   7/40                 0/5                    0/11
 (N 53)                                                                (0%)                 (17.5%)               (0%)                    (0%)
 Organic dysphonia                                                     0/10                   4/39                 0/7                    0/20
 (N 49)                                                                (0%)                 (10.3%)               (0%)                    (0%)
 Total                                                                 0/42                 22/129                0/21                     0/6
 (N 171)                                                               (0%)                (17.1%)*               (0%)                    (0%)
UVFP: Unilateral Vocal Fold Paralysis; *males vs females: p < 0.05.




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                                                                 Subjective perception of dysphonia and results of voice therapy by gender




fold nodules, pharyngolaryngeal reflux dysphonia 15, vocal     ing the time-to-diagnosis despite perceptually more severe
fold paralysis and vocal fold oedema. Furthermore, some        symptoms. Females demonstrate a higher emotional impact
Authors report that in the dysphonic population there are      of dysphonia, especially in unilateral recurrent nerve laryn-
more females than males and that children and adolescents      geal palsy diagnosis and organic voice disorders, probably
represent a minority of the sample 14,16.                      because of women being more willing to admit psychologi-
In agreement with these data, our dysphonic popula-            cal distress.
tion was mainly female. Moreover, females had a higher         The literature has assessed sex variability in treatment
prevalence of all-cause dysphonia probably because, as         adherence; Rangabashyam et al. 20 found that gender was
is known, they use more healthcare resources than males.       an independent factor for the nonadherence to the head
Nevertheless, the distribution of a dysphonia diagnosis did    and neck tumour board recommendations. A systematic
not differ between the two genders and reflected that in the   study on voice therapy adherence and influencing factors
general population 16.                                         was first outlined by Van Leer et al. 21. Age, distance to
The literature reports few papers about the sex-related dif-   the clinic, marital status, insurance status, medical diag-
ferences of the time between the onset of symptoms and         nosis and auditory-perceptual rating of dysphonia did not
initiation of therapy in cancer patients 17, but no study to   demonstrate a relationship to voice therapy adherence
date has examined the time-to-diagnosis of benign voice        in previous quantitative studies 22-25. On the contrary, it
disorders. As such, the current study specifically focused
                                                               was demonstrated that patients who underwent evalua-
on the time lag to diagnosis basing on the sex/gender re-
                                                               tion by a otolaryngologist and speech-language patholo-
lated differences. Most research has described disparities
                                                               gist not in the same day showed lower adherence to voice
about the timely recognition of symptoms by patients. The
                                                               therapy 26. Moreover, Pasternak et al. 27 highlighted the
onset of symptoms may not only be different among men
                                                               negative impact of having fewer school-aged children in
and women, but acknowledgment and validation of symp-
                                                               the household. The voice therapy initiation rate obtained
toms by healthcare providers may be susceptible to sex-
based differences. One study noted that when physicians        in our study did not differ between males and females.
review cases in which patients present significant symp-       In our division, we routinely perform double assessment
toms, as well as a recent emotionally upsetting event, they    (speech-therapist and physician) in the same day in all
are much more likely to consider a man’s symptoms as           cases. The number of patients who refused voice therapy,
disease-related and that of a woman due to an “emotional       attendance at therapy sessions and prevalence of prema-
upset” 18. Interestingly, in the current study we demon-       ture end of therapy did not differ by sex, demonstrating
strated that women were not different in the time-to-diag-     a similar awareness of dysphonia. This result is consist-
nosis compared to men. On the other hand, women came           ent with recent studies that ruled out the role of gender
to the diagnosis with a subjectively, auditory-perceptually    in voice therapy adherence 22,23 and reinforced the pro-
and acoustically significantly poorer quality of voice than    spective of the absent relationship between voice therapy
men. Therefore, considering both results, it would seem        initiation and most patient- and disease-related factors.
that males may be more sensitive to voice changes or that      Finally, voice therapy was effective in both males and
females have a “wait-and-see” approach; however, the im-       females. Our results showed that, despite a similar im-
pact of voice disorders on the quality of life is worse in     provement of the auditory perceptual score, the subjec-
females. In this regard, we assume that the association of     tive perception of the biopsychosocial impact of the voice
two factors may explain the difference: if on one hand the     disorder decreased more in women probably because of
well-known high male to female ratio of laryngeal cancer       the worse subjective perception of dysphonia before VT.
may alert the subject themself or the general practitioner,
on the other the opposite ratio of the functional dysphonia    Conclusions
and benign lesions 1 may delay the diagnosis in women.
On the other hand, women in our society are generally ex-      Our study showed a higher prevalence of voice disorders in
pected to occupy a nurturant role, both performing daily       females. Awareness of dysphonia was not gender related.
essential household tasks and taking on the major respon-      Females started with worse voice subjective perception and
sibility for the care of children, spouses and aged rela-      acoustic analysis, but they perceived greater improvement
tives 19. Therefore, as a consequence of social obligations    after therapy.
towards others and the corresponding demands of others,
women are often unable to successfully assume the role of      Conflict of interest statement
“sick”, thus ending up neglecting their health and lengthen-   The authors declare no conflict of interest.



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M.R. Marchese et al.




Funding                                                                      10
                                                                                  Banai IP. Voice in different phases of menstrual cycle among natu-
This research did not receive any specific grant from fund-                       rally cycling women and users of hormonal contraceptives. PLoS One
                                                                                  2017;12.8:e0183462. https://doi.org/10.1371/journal.pone.0183462
ing agencies in the public, commercial, or not-for-profit                    11
                                                                                  Zhukhovitskaya A, Battaglia D, Khosla SM. Gender and age in be-
sectors.                                                                          nign vocal fold lesions. Laryngoscope 2015;125:191-196. https://doi.
                                                                                  org/10.1002/lary.24911
Author contributions                                                         12
                                                                                  Xue SA, Fucci D. Effects of race and sex on acoustic features of
Conceptualisation: LD and MRM. Methodology: MRM                                   voice analysis. Percept Mot Skills. 2000;91:951-958. https://doi.
and YL. Investigation: TDC, GM and VT. Data curation:                             org/10.2466/pms.2000.91.3.951
MRM, YL and TDC. Writing – original draft preparation:
                                                                             13
                                                                                  Schindler A, Ottaviani F, Mozzanica F, et al. Cross-cultural adapta-
                                                                                  tion and validation of the voice handicap index into Italian. J Voice
MRM, YL and TDC. Writing – review and editing: MRM,                               2010;24:708-714
LD, JG. Supervision: JG and LD. All authors have read and                    14
                                                                                  Mozzanica F, Ginocchio D, Barillari R, et al. Prevalence and voice
agreed to the published version of the manuscript.                                characteristics of laryngeal pathology in an italian voice therapy-seek-
                                                                                  ing population. J Voice 2016;30:774.e13-774.e21.
Ethical consideration                                                        15
                                                                                  Van Houtte E, Van Lierde K, D’Haeseleer E, et al. The prevalence of
This study was approved by the Institutional Ethics Com-                          laryngeal pathology in a treatment-seeking population with dyspho-
                                                                                  nia. Laryngoscope 2010;120:306-312.
mittee of A. Gemelli IRCCS University Hospital Founda-
                                                                             16
                                                                                  Cohen SM, Kim J, Roy N, et al. Prevalence and causes of dysphonia
tion as retrospective case series study.
                                                                                  in a large treatment-seeking population. Laryngoscope 2012;122:343-
The research was conducted ethically, with all study pro-                         348. https://doi.org/10.1002/lary.22426
cedures being performed in accordance with the require-                      17
                                                                                  Azap RA, Hyer JM, Diaz A, et al. Sex-based differences in time to
ments of the World Medical Association’s Declaration of                           surgical care among pancreatic cancer patients: a national study of
Helsinki.                                                                         Medicare beneficiaries. J Surg Oncol 2021;123:236-244. https://doi.
Written informed consent was obtained from each partici-                          org/10.1002/jso.26266
pant/patient for study participation and data publication.
                                                                             18
                                                                                  Chiaramonte GR, Friend R. Medical students’ and residents’ gender
                                                                                  bias in the diagnosis, treatment and interpretation of coronary heart
                                                                                  disease symptoms. Health Psychol 2006;25:255-266. https://doi.
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