doi: 10.1590/1982-0216201618211215 Originl rticles Glottl function self-perception nd uditory-perceptul nlysis of municipl school techers Autopercepção d função glótic e nálise perceptivouditiv de professores de escols municipis Elisângel Sntos Crregos (1) Vnine Lel Silv (1) Aline Brito (2) Rodrigo Dornels (1) Roxne de Alencr Irineu (1) (1) Universidde Federl de Sergipe, UFS, Lgrto, Sergipe, Brsil. (2) Pontifíci Universidde Ctólic de São Pulo, PUC-SP, São Pulo, São Pulo, Brsil. Conflict of interest: non-existent Received on: July 22, 2015 Accepted on: Ferury 06, 2016 Miling ddress: Roxne de Alencr Irineu Deprtmento de Fonoudiologi - Universidde Federl de Sergipe Ru Ludelino Freire, 184, 2º Andr, Centro Lgrto - SE Brsil CEP: 49400-000 E-mil: roxneirineu@gmil.com ABSTRACT Purpose: to correlte dt from the self-perception nlysis nd vocl techer perception. Methods: the study included 52 techers of oth genders (39 women nd 13 men) from municipl schools in Lgrto, ged etween 24 nd 54. Dt collection ws crried out in schools in two steps: ppliction of self-ssessment protocol function index glótic nd the perceptul voice evlution protocol Consensus Auditory- Perceptul Evlution of Voice. Dt were nlyzed quntittively nd orgnized into dtse to e treted sttisticlly. Results: the study reveled 80% of voice ltertion second techers voice perceptul evlution nd 59.6% in the vocl chnge self-reported y the techer. It hs een found tht the min complints of techer refer to items vocl ftigue nd voice reks or is different nd vocl symptoms more checked y experts includes tension nd horseness. There ws no sttisticlly significnt correltion etween protocol. Conclusion: no correltion etween the protocols cn e justified s techer desensitiztion s the vocl prolem nd lso y dpting the new voice. With this ecomes extremely importnt speech therpy cre to ensure self-perception nd vocl helth. Keywords: Fculty; Occuption Helth; Voice RESUMO Ojetivo: correlcionr ddos d nálise perceptivouditiv e d utopercepção d função glótic de professores de escols municipis. Métodos: prticiprm deste estudo 52 professores de mos os sexos, sendo 39 mulheres (75%) e 13 homens (25%) de escols municipis d cidde de Lgrto, n fix etári compreendid entre 24 e 54 nos. A colet de ddos foi relizd ns escols em dus etps: plicção do questionário de utovlição Índice de Função Glótic e do protocolo de vlição fonoudiológic perceptivouditiv d voz. Os ddos form nlisdos quntittivmente e orgnizdos em um nco de ddos e receerm trtmento esttístico. Resultdos: o estudo pontou 80% de lterção vocl em professores segundo vlição perceptivouditiv d voz e 59,6% de lterção vocl utorreferid pelos professores n função glótic. Foi consttd que s principis queixs dos professores são referentes os itens fdig vocl e voz quer ou está diferente e os sinis vocis mis oservdos pelos especilists são tensão e rouquidão. Não houve correlção esttisticmente significnte entre os instrumentos utilizdos. Conclusão: usênci de correlção entre os instrumentos pode ser justificd como um dessensiilizção do professor qunto o prolem vocl, ocsiond pel dptção à nov voz lterd. Com isto, torn-se de extrem importânci tução fonoudiológic pr grntir utopercepção e súde vocl. Descritores: Docentes; Súde do Trlhdor; Voz
482 Crregos ES, Silv VL, Brito A, Dornels R, Irineu RA INTRODUCTION Professionls who use their voices s the min working tool re susceptile to develop vocl disorders. This wy, the techer hs een the focus of severl studies in the Speech-Lnguge Pthology field, since this ctegory dels with greter unsnitry work conditions 1.2 relted to voice disorders 3. Through the intrinsic reltionship etween voice nd qulity of life 4 is understood s of prmount importnce tht the reserch on the impct of voice chnges in techers use self- ssessment tools 5, so tht we cn understnd the perspective of these professionls with respect to voice disorders nd its influence in their dily life 6. A study showed tht techers re stisfied with the qulity of life nd with their voice, which my revel n issue in understnding the helth-disese process nd spects relting to work, qulity of life nd helth tht my relte to voice disorders 7. In ddition, other reserch on self-perception, which involved 29 techers with vocl complints, pointed out tht the techers relize chnges in their voices; however, the impct on their qulity of life is poorly understood or undervlued 8. The voice uditory-perceptul evlution performed y speech-lnguge pthologists represents low-cost tool tht cn ssist in the identifiction of the professionls tht need to e referred to specific exmintions nd possily, voice therpy, s well s offer the necessry nd sufficient llownces to conduct the vocl cords screening with techers in school environments 9. Among the vocl evlution tools, the CAPE-V protocol provides dt to speech-lnguge pthologist on the degree of severity of vocl disorder through the uditory-perceptul evlution. In study tht verified the reltion etween the otorhinolryngologicl evlution nd the CAPE-V in the voice of techers with vocl complints, the findings rought significnt ssocition etween the two evlutions 10. A reserch tht imed to lern out the working conditions nd the level of informtion out the voice of higher eduction professionls found tht 77.7% of the respondents hd self-perception which coincided with the findings of the uditory-perceptul evlution 11. The lck of wreness of techers regrding voice disorders suggests the need for ctivities relted to the promotion of vocl helth tht cn e conducted in schools through lectures nd specific guidelines 12. The workers helth is field of prctices nd knowledge tht emerges from the collective helth, iming to understnd nd intervene in the reltionship etween work nd helth-disese process, s well s the promotion nd protection of workers helth 13.14. In this perspective, the work-relted voice disorder (WRVD) is defined s ny form of chnge in voice tht is directly relted to its use during the professionl ctivity y reducing or preventing the communiction of the worker 14. In 1997, the Brzilin Federl Council of Speech-Lnguge Pthology referred report to speech-lnguge pthologists where they stte tht chnges in the vocl trct could e prt of n occuptionl disese. However, the correltions etween voice nd work need to e defined nd consolidted so tht the diseses cn e notified s disese work 15.16. In view of the exposed, the present reserch imed to correlte the dt from the uditory-perceptul evlution nd the glottl function self-perception of municipl schools techers METHODS This study is included in reserch project entitled Voice in teching: workers helth issue, which ws pproved y the Reserch Ethics Committee of the Federl University of Sergipe under the numer CAAE 17167413.3.0000.5546. 52 techers of oth genders, of which 39 women (75%) nd 13 men (25%) who teches in different eduction levels (from erly childhood eduction to the eduction of young people nd dults) of municipl schools in Lgrto/SE, ged etween 24 nd 54 yers. The reserch requested n uthoriztion for schools nd ll techers tht prticipted, nd they signed the Free nd Informed Consent Term (FICT), ccording to Resolution No 466/2012 which dels on ethics in reserch. As inclusion criteri, the techer should e enrolled on the Secretrit of Eduction in Lgrto-SE. The techers in sick leve were not included in the study. Thus, the popultion of the reserch included 52 techers prticipting in totl of 78 respondents. Dt collection ws crried out in schools in two steps: ppliction of the Glottl Function Index (GFI) self-ssessment questionnire nd the Consensus Protocol of Voice Auditory-Perceptul Evlution (CAPE-V). The GFI self-ssessment questionnire consists of four questions relted to issues ffecting the glottl function nd the degree of the disorder, nmely: I hve to mke n effort to spek, I feel sense of distress or
Self-perception in techers 483 pin fter speking, I feel vocl ftigue (wek voice when I spek) nd my voice reks or is different. The nswers ssess the degree or severity of the disorders, from 0 for this is not prolem to 5 for this is very ig prolem 17. The totl score is clculted y the sum of the responses of the four questions nd the vlue of three s totl is suggested s minimum score. This reserch tool ws nswered y the techers prticipting in the reserch. The CAPE-V is voice uditory-perceptul evlution tool, which ws developed y group of Americn speech-lnguge pthologists who re voice specilists. The voice uditory-perceptul evlution is performed y the speech-lnguge pthologist, nd it ssesses six predetermined prmeters, with the possiility of dding two dditionl prmeters, in three different tsks: sustined vowels, specific phrses nd spontneous converstion. The six prmeters included re the following: glol severity of chnge, roughness, rethiness nd tension. In ddition to the prmeters devition reported, the speech-lnguge pthologist should lso indicte whether the chnge indicted is consistent (C) or intermittent (I). The ssessment is represented y liner nlogue scle, of 10 centimeters in length (from 0 to 100mm), where the specific ssessment of ech prmeter must e reported 18. The degree of intensity is chrcterized s discrete, discretely moderte, moderte, modertesevere nd severe. The min ojective of this protocol is to identify the severity of vocl prolem through the humn uditory-perceptul evlution of competent professionl nd to investigte the need for complementry exmintions for the vocl evlution. Therefore, this instrument ws pplied in second moment, in ll techers, in school room, with controlled mient noise. During the ssessment, smple of the voice ws recorded in ccordnce with the specifictions descried in CAPE-V, in portle digitl recorder COBY. Susequently, these smples were evluted y speech-lnguge pthologist, supervisor techer, specilist in the field of voice nd five undergrdutes in speech lnguge pthology. Dt were nlyzed quntittively nd orgnized into dtse to e treted sttisticlly. The Person correltion coefficient ws used, which chrcterizes mesure of the degree of the liner reltion etween two quntittive vriles. This coefficient rnges etween -1 nd 1. The vlue 0 (zero) mens tht there is no liner reltionship, the vlue 1 indictes perfect liner reltionship nd the -1 vlue lso indictes perfect liner reltionship, ut reversed, tht is, when one of the vriles increses, the other one decreses. The closer you re to 1 or -1 vlue, the stronger is the liner ssocition etween the two vriles 19. A comprison of the findings ws conducted with the gender nd the ge rnge of the prticipnts of this reserch. Another test used ws the Biseril Point Correltion Coefficient, which is derived from the Person Liner Correltion Coefficient. This method is indicted when one of the vriles is dichotomous (Y) nt the other one is continuous (X). Dichotomous vriles re the qulittive vriles for which there re only two possile nswers Yes/No, sick/not ill, deth/live, etc. 20. The estimtor of the Phi Coefficient Correltion ws lso included, which ws otined from the estimtor of the Person Liner Coefficient, nd which is pplied in cses with dichotomous vriles 21. The Kendll correltion coefficient 22 ws lso pplied, which is correltion mesure used when t lest one of the vriles eing nlyzed is ordinl, or presents gret devition from the norml 23. RESULTS The results of the GFI questionnire showed tht 31 (59,6%) of the techers self-reported the complint in some level of this questionnire, totling vlue greter thn three, with ws the minimum score estlished in the generl degree. Women showed results in higher frequency, since 24 (61%) of the women complined out voice chnge. With respect to the men techers, seven men (53%) reported voice complint.
484 Crregos ES, Silv VL, Brito A, Dornels R, Irineu RA Effort to spek Sense of distress when speking Vocl ftigue Voice reks or is different Womn Mn Figure 1. Frequency of responses to items of the Glottl Function index divided y gender Roughness Brethiness Tension Mn Womn Figure 2. Frequency of responses to items of the CAPE-V distriuted y sex
Self-perception in techers 485 Effort to spek Sense of distress when speking Vocl ftigue Voice reks or is different 24 to 34 yers old 35 to 44 yers old 45 to 54 yers old Figure 3. Frequency of responses to items of the Glottl Function index divided y ge rnge Roughness Brethiness Tension 24 to 34 yers old 35 to 44 yers old 45 to 54 yers old Figure 4. Frequency of responses to items of the CAPE-V distriuted y ge rnge
486 Crregos ES, Silv VL, Brito A, Dornels R, Irineu RA Roughness Brethiness Tension Mn Womn Figure 5. Averge frequency of constnt vocl chnges in CAPE-V distriuted ccording to the vrile gender Effort to spek Sense of distress when speking Vocl ftigue Voice reks or is different Mn Womn Figure 6. Averge frequency of responses to items of the Glottl Function index ccording to the vrile gender
Self-perception in techers 487 Tle 1. Correltion of the Glottl Function Index instruments with CAPE-V GFI CAPEV Roughness Brethiness Tension r=-0.04 r=0.29 r=- 0.16 r=0.04 p-vlue= 0.78 p-vlue= 0.04* p-vlue=0.26 p-vlue=0.78 Effort to spek p-vlue=0.09 p-vlue=0.13 p-vlue=0.29 p-vlue=0.00 Sense of distress p-vlue=0.53 p-vlue=0.36 p-vlue=0.53 p-vlue=1.00 when speking p-vlue=0.17 p-vlue=0.21 p-vlue=0.13 p-vlue=0.14 Vocl ftigue p-vlue=0.23 p-vlue=0.14 p-vlue=0.36 p-vlue=0.32 p-vlue=-0.05 p-vlue=0.20 p-vlue=-0.11 p-vlue=0.16 Voice reks or is p-vlue=0.72 p-vlue=0.16 p-vlue=0.44 p-vlue=0.26 different p-vlue=0.01 p-vlue=0.13 p-vlue=-0.18 p-vlue=0.10 p-vlue=0.94 p-vlue=0.36 p-vlue=0.20 p-vlue=0.48 Phi Correltion Coefficient(YULE, 1912) Biseril Point Correltion(GUILFORD, 1950) * indictes sttisticlly significnt vlues (p<0.05) Tle 2. Correltion of the Glottl Function Index instruments with CAPE-V y gender CAPEV Degree CAPEV Chnge GFI Degree GFI Chnge Phi Correltion(YULE, 1912); Biseril Point Correltion(GUILFORD, 1950) * indictes sttisticlly significnt vlues (p<0.05) Vrile Gender p-vlue Roughness 0.29 0.04* Brethiness -0.32 0.02* Tension 0.18 0.21 CAPE-V 0.44 0.00* Roughness 0.33 0.02* Brethiness -0.25 0.07 Tension 0.17 0.23 CAPE-V 0.28 0.04* Effort to spek -0.32 0.02* Sense of distress or pin when speking -0.20 0.16 Vocl ftigue -0.19 0.18 Voice reks or is different -0.32 0.02* GFI -0.20 0.04* Effort to spek -0.19 0.20 Sense of distress or pin when speking -0.32 0.89 Vocl ftigue -0.12 0.40 Voice reks or is different -0.05 0.72 GFI -0.07 0.62 DISCUSSION The predominnce of women who prticipted in the smple coincides with the verge cited in the literture out the profile of the techer popultion 6. This ws lso the gender with greter prevlence nd severity of self-reported voice chnge. The role of women in society nd the overlods of the work ssigned to them cn contriute to the occurrence of vocl prolems 23. However, the uditory-perceptul evlution showed tht the prevlence of vocl chnges is greter in men, dt tht ws not found in other reserches². It ws oserved in the uditory-perceptul evlution of techers tht here ws predominnce of tension nd roughness prmeters in the nlysis of gender nd ge rnge vriles. The symptoms relted to the glottl function (GFI) of techers showed tht women presented higher
488 Crregos ES, Silv VL, Brito A, Dornels R, Irineu RA level of vocl ftigue nd voice reks compred to men; however these symptoms were lso present in the mle smple in nother study 4. As regrds the ge, the techers etween 45 nd 54 yers old hd higher levels of vocl complints thn the other ge groups. A color test ws performed with respect to items of the two instruments nd no significnt reltionship ws found etween ge rnge nd voice chnge, study lso points out tht the ge is not relted to the vocl chnge in techers 24. Despite not presenting significnt correltions etween the vlues otined in the two instruments, it ws oserved higher frequency of vocl chnges in the ge rnge etween 45 nd 54 yers old. The literture highlights tht the ge rnge vrile deserves greter ttention, since the higher the ge, the lower the vocl efficiency, this is due to series of lryngel chnges due to the ging process 25. The present study showed prevlence of vocl chnges in techers from the voice uditory-perceptul evlution, which is similr to the results in other reserches tht hve found 79.6% of chnges in the voice chrcteristics of techers 26. In this reserch, roughness nd tension were the most mentioned prmeters, repeting the results otined in nother study tht highlights the tension (81.9%) nd roughness (71.5%) s the most oserved vocl prolems 27. These symptoms my e relted to the vocl misuse nd use, usully found in this popultion, s well s the unhelthy wter drinking hits nd few hours of sleep 28. In this study there ws prevlence of self-reported vocl prolems when compred to the uditoryperceptul evlution. The most frequent vocl complints were vocl ftigue nd voice reks or is different. A similr study lso highlights the vocl ftigue s one of the most frequent complints (72.6%), nd this symptom is directly relted to the lck of informtion of pproprite vocl techniques to tech, tension when speking nd unfvorle working conditions, mong others 3. No sttisticlly significnt correltion ws found etween the findings of the CAPE-V nd the GFI. In order to otin the correltion of the instruments, the numers of greements should e greter thn the numers of disgreement; however, the study otined similr numer of oth. Corroorting with this finding, study lso found n sence of correltion etween oth instruments used in the study 11. This finding my e justified y the lck of wreness of techers regrding their voice prolems. It cn e ssumed tht y living long time with the voice chnge, the techers dpt to it, thus losing the ility to feel possile vocl prolem, s oserved in other studies 24. Or the voice chnce is not severe enough to interfere drmticlly in the performnce of the teching work nd, therefore, is considered not relevnt. The voice dpted, defined s voice stle nd resistnt to specific use relted to the work, cn lso e justifiction to the findings of this reserch. It is possile to pply the voice dpted term in ll situtions in which the voice is socilly dptle nd is le to communicte the emotionl messge of the speech, with frequency, intensity, modultion nd projection pproprite to the ge nd the gender of the speker. Even in the presence of structurl chnges in the vocl cords, it is possile to hve phontion pprtus tht produces n cceptle voice, since there is significnt percentge of workers who use the voice more intensively nd tht cn present injuries without symptoms nd with good chnces to remin stle nd symptomtic long the months or yers of their lor exercise 29. Another spect tht should e considered in the findings of this reserch is tht the techer presents difficulty to identify the tension symptom s prolem of voice, chrcterizing it s norml. The results of oservtion nd exmintions more esily interpreted s vocl prolem re relted to the ones tht generte significnt sense of distress, such s: horseness, loss of voice, pin nd urning throt senstion when speking 12. The only item in which sttisticlly significnt correltion ws found is relted to rethiness nd effort to tlk. The rethiness prmeter is relted to the likely presence of incomplete closure of the glottis nd, consequently, the techer will require greter effort to spek due to the ir expelled in the phontory process 28. CONCLUSION The study showed tht mny techers self-reported vocl chnge, fct tht ws quite frequent, especilly in women. The most mentioned vocl symptoms y the techers were vocl ftigue nd voice reks or is different, demonstrting tht the GFI presents s questionnire tht lists the specificlly orgnic symptoms nd, therefore, it does not directly ddress
Self-perception in techers 489 the consequences of vocl chnges in the socil, psychologicl nd professionl res. Despite the low correltion etween the GFI nd CAPE-V instruments found in this study, the ppliction of two protocols to investigte nd understnd the vocl disorders is significnt. The techers most likely didn t show ny concern to their voice prolems, y the fct they live for long time with the disorder, dpting to their new nd chnged voice. In ddition, the initil stge of vocl disorders usully does not cuse work disility, nd certin symptoms re often neglected s eing understood s norml on techers. Given the findings, it is elieved tht the speechlnguge pthologist work is relevnt for techers, to work in progrms tht ensure the self-perception, nd ccelerte the development of ctions tht promote the vocl helth nd, consequently, reduces the high levels of voice disorders relted to working conditions. To this end, in fct, it is necessry the pprovl of vocl helth pulic policies iming to the pulic ddressed in this study, since tht techers elong to professionl ctegory tht is essentil for the development of society, despite the lck of ttention from the pulic uthorities nd sic rights. REFERENCES 1. Ferreir LP, Mrtz ML. Distúrio de voz relciondo o trlho: experiênci dos CEREST. Bep.2010;7(76):13-9. 2. Roy N, Merril RM, Thieult S, Prs RA, Gry SD, Smith EM. Prevlence of voice disorders in techers nd the generl popultion. J Speech Lng Her Res. 2004;47(2):281-93. 3. Drgone MLS, Ginnini SPP, Ditscheiner ÉS, Andrde BMR, Ferreir LP. Voz do professor. 2013. Acesso em: 20/12/2015. Disponível em: http:// www.sf.org.r/portl/voz_profissionl2013/ 4. Ferreir LP, Ginnini SPP, Ltorre, MRDO, Zenri MS.Distúrio de voz relciondo o trlho: propost de um instrumento pr vlição de professores. Distúr Comun. 2007;19(1):127-36. 5. Spin AL, Munsell R, Sndlo K, Gusmão R, Crespo A. Correlção d qulidde de vid e voz com tividde profissionl. Rev Brs Otorrinolringol., 2009;75(2):275-9. 6. Behlu M, Tuty AS, Zmon F, Oliveir G. Comprção dos escores dos protocolos QVV, IDV E PPAV em professores. Rev Soc Brs Fonoudiol. 2011;16 (3):273-8. 7. Pentedo RZ. Relção entre súde e trlho docente: percepções de professores sore súde vocl. Rev Soc Brs Fonoudiol. 2007;12(1):18-22. 8. Cost DB, Lopes LW, Silv EG, Cunh GMS, Almeid LNA, Almeid AAF. Ftores de risco e emocionis n voz de professores com e sem queixs vocis. Rev CEFAC. 2013;15(4):1001-10. 9. Lim-Silv MFB, Ferreir LP, Oliveir IB, Silv MAA, Ghirrdi ACAM. Distúrio de voz em professores: utorreferênci, vlição perceptiv d voz e ds pregs vocis. Rev Soc Brs Fonoudiol. 2012;17(4):391-7. 10. Snders AP, Moreir NM, Aud LA, Brros ALSM. Estudo sore percepção vocl e perceptivouditiv pré e pós-plicção de exercícios de quecimento vocl de professores do ensino superior. Anis Eletrônico VIII EPCC Encontro Interncionl de Produção Científic Cesumr UNICESUMAR Centro Universitário. Editor CESUMAR. Prná Brsil; 2013. 11. Moris EPG, Chiri BM, Azevedo R. Correlção Entre vlição perceptivo-uditiv, uto-vlição vocl e qulidde de vid em voz em professores; 18 Congresso Brsileiro de Fonoudiologi. Anis. Curiti(PR); 2010. 12. Pentedo RZ, Pereir IMT. Qulidde de vid e súde vocl de professores. Rev Súde Púlic. 2007;41(2):236-43. 13. Bernrdi APZ. Fonoudiologi n súde coletiv: um áre em crescimento. Editoril II. Rev CEFAC. 2007;9(2);339-40. 14. Lcz FAC. O cmpo súde do trlhdor: Resgtndo Conhecimentos e Prátics Sore s Relções Trlho-Súde. Cd. Súde Púlic. 2007;23(4):757-66. 15. Cost HO. Distúrios d voz relciondo com o trlho. In: Mendes, R, editor. Ptologi do trlho. São Pulo: Atheneu; 2003. p. 1283-93. 16. Ferreir LP, Bernrdi PA. Distúrio de voz relciondo o trlho: resgte histórico. Distúr Comun. 2011;23(2):233-6. 17. Priuisiene R, Bceviciene M, Uloz v, Vegiene A, Antusev J. Vlidtion of the Lithunin Version of the Glottl Function Index. J Voice. 2012;26(2):e73-e8. 18. Behlu M. Consensus Auditory- Perceptul Evlution of Voice (CAPE-V), ASHA 2003. Refletindo sore o novo. Rev Soc Brs Fonoudiol. 2004;9(3):187-9.
490 Crregos ES, Silv VL, Brito A, Dornels R, Irineu RA 19. Person K. Notes on regression nd inheritnce in the cse of two prents. R. Soc. open sci. 1985;58(4):240-2. 20. Guilford JP. Fundmentl sttistics in psychology nd eduction. 4th ed. New York: McGrw-hill Book, 1950. 21. Yule GU. On the Methods of Mesuring Assocition Between Two Attriutes. J. R. Stt. Soc.1912;75:579-652. 22. Kendll MA.New Mesure of Rnk Correltion. Biometrik. 1938;30:81-9. 23. Moris EPGM, Azevedo RR, Chiri BM. Correlção entre voz, utovlição vocl e qulidde de vid em voz em professors. Rev CEFAC. 2012;14(5):892-900. 24. Fuess VLR, Lorenz MC. Disfoni em professores do ensino municipl: prevlênci e ftores de risco. Rev Brs Otorrinolringol. 2003;69(6):807-12. 25. Kooijmn PGC, Thoms G, Grmns K. de Jong FICRS. Psychosocil Impct of the Techer s Voice Throughout the Creer. J Voice. 2005;21(3):316-24. 26. Simões M, Ltorre MRDO. Prevlênci de lterção vocl em educdors e su relção com uto-percepção. Rev Súde Púlic. 2006;40(6): 1013-8. 27. Mestre LR. Voz do professor: relção entre vlição perceptiv-uditiv, utorrefrênci sintoms e índice de desvntgem [Dissertção]. São Pulo (SP): PUC; 2012. 28. Ferreir LP, Ltorre MR, Ginnini SP, Ghirrdi AC, Krmnn DF, Figueir EE. Influence of usive vocl hits, hydrtion, mstiction, nd sleep in the occurrence of vocl symptoms in techers. J Voice. 2010;24(1):86-92. 29. Behlu M, Azevedo R, Pontes P. Conceito de voz norml e clssificção ds disfonis. In: Behlu M (Org.) Voz: o livro do especilist. 1ª. ed. Rio de Jneiro: Revinter; 2004. p.54-84.