Do face masks have an impact on the voice?

By Olympia Karagkouni, Excecutive Speech Therapist

and Master´s student at SAERA

 

As we all struggle to get through our everyday life during the COVID-19 pandemic era, we are called to comply to a number of health safety regulations. One of them is the obligation to wear a protective face mask in all public spaces. A vast number of people worldwide, wear face masks at their working environments, during essential everyday activities and leisure activities. But how does this practice affect our daily living? Does it have an impact on communication? Could there be cooccurrence of functional, physical and emotional consequences?

 

A study conducted in 2020, by speech and language therapist Olympia Karagkouni, in Greece, investigated the effects of the use of protective face mask on the voice and its relation to self-perceived voice changes.  This project was considered by its reviewers to be very valuable and extremely aligned with the needs of the scientific community in order to achieve better understanding of the potential effects caused by the use of face masks.

 

The research was conducted by using an online questionnaire, distributed through social media platforms. It was addressed to people who wore protective face mask at their working environment, regardless of their profession. The questionnaire included questions about the participants profession, working hours, hours of wearing protective mask, the type of mask used and for how long they have been using systematically a face mask at work. Next, the participants had to answer to five groups of questions in order to self-evaluate their voice and state the frequency and severity of the symptoms they may have experienced during the mask usage period. Each group examined different parameters of the voice perception and they included the Speech Difficulties and the Mask Related Behaviors caused by the use of face mask, alterations in the Voice Perceptual Features, the Vocal Tract Discomfort levels and the Greek version of the Voice Handicap Index.

 

Results: The results showed that the use of protective face mask increases the self-perception of changes in the voice, especially in the voice-breathing coordination and has great effect on the intelligibility and overall communication.

 

speech difficulties

The majority of people stated that they have to speak louder and that they have noticed alterations in the perceptual features of their voice, with hoarseness and volume being the most frequently affected. Almost every symptom on the Vocal Tract Discomfort Group was present. The participants reported that Dry, Lump in Throat, Tight sensations and Short Breath were the most severe, and Dry and Short breath being the most common among them. Physical, Functional and Emotional affectations were also observed through the Voice Handicap Index.

 

In total of 143 individuals, 62 (43.2%) of them had 5 or more coexisting problems in speaking due to mask use while 67 (47.1%) of the participants had 1 to 4 problems. It was stated by almost half of the population that it was hard for them to be heard and understood by others while wearing the mask, and almost 7/10 claimed that they need to speak louder to overcome this barrier. It is known that face masks function as acoustic filters for speech that attenuate the high frequencies by 3 – 12 dB according to the material of the mask (Goldin et al., 2020). Therefore, it could be assumed that a speaker who wears face mask, needs to increase the usual vocal loudness in order to be heard.

 

Additionally, 4/10 participants claimed to also experience short breathiness and fatigue. Inefficient voice-breathing coordination and phonation on residual air, also increases tension and adds to the phonatory effort (Mathieson, 2001). Breathing and lung air volume also affects directly the loudness of the speakers’ voice. It is clear that lower and upper airway functions are critical for both ventilation and communication, often simultaneously. Further, a breakdown in one function can impact the other (Lewandowski et al. 2016). When speaking with a face mask, an obstruction of the upper airway occurs, as both the nose and mouth are covered by the face mask material. This could possibly lead to changes in the amount of the inhaled air, and the speaker may feel the need to compensate by increasing the frequency of inhalations. Furthermore, large number of the participants experienced difficulties in transmitting their message, especially the non-verbal cues which facilitate the understanding (such as feeling given through facial expressions). They often have to repeat their utterances, which eventually leads to fatigue.

 

These adopted behaviors by the participants of this study, conform with effortful phonation pattern, which according to literature is a key component in hyperfunctional voice disorders. Hyperfunctional patterns of phonation, particularly increased voice loudness, leads to deterioration in the voice. Inefficient voice-breathing coordination and phonation on residual air, also increases tension and adds to the phonatory effort (Mathieson, 2001). These hyperfunctional speaking patterns place great amount of stress on the laryngeal musculature. If those behaviors persist for long periods of time, it is highly possible that alterations in the function and/or physiology of the vocal track may appear, causing hyperfunctional dysphonia (or MTD).

 

More than 50% of the participants self-assessed the perceptual features of their voice to be altered due to the use of face mask, in Moderate or Severe intensity, 59,9% Hoarseness, 63,1% Volume, 54,8% Pitch, 55,8% Volume Stability in total.

 

sd2

When alterations in the perceptual features of the voice are observed, a disorder in the function of the vocal tract may be suspected. These findings are in line with the hypothesis of this study, that speaking with face mask increases the self-perception of voice changes and the likelihood of developing compensatory strategies that may lead to changed phonatory patterns coherent with voice misuse.  

 

The voice difficulties caused by the use of face mask, led 21 (14%) of the participants to visit a specialist and the 1/3 of them to receive medication as therapy. Also, individuals that had voice problems in the past had higher scores in every group, indicating that high risk population had increased perception of discomfort by the mask usage.

 

An unexpected finding, was that people who wore the mask for more than 8 hours, scored lower scores from people who wore it for 6-8 hours, even from those who wore it for 4-6 hours, in almost every scale. It seems that after this long period of obligatory protective face mask usage, people get more and more accustomed to the new situation and seem to adopt new strategies to cope with the difficulties that arise. It can be assumed that people may have started to better understand the implications that the face mask creates in communication, and may have adjusted their vocal use patterns. If proper education on voice hygiene and voice training would have been implemented, the participants may have experienced less severe voice problems.

 

Conclusion: The use of protective face mask increases the vocal effort of the speaker, affects the voice-breathing coordination, limits the overall communication, alters the perceptual features of the voice, increases vocal track discomfort levels and results in psychosocial and socioemotional difficulties. All these affectations may result to the establishment of a voice disorder, especially in high-risk population.

 

For further reading and full article, please follow the link below: https://www.jvoice.org/article/S0892-1997(21)00149-1/fulltext