Wind instrumentalists’ work-related vocal tract discomfort

Abstract

BACKGROUND:

Wind instrumentalist use the vocal tract intensively in their professional activities, which can lead to the development work-related voice disorders.

OBJECTIVE:

To analyze the perception of vocal tract discomfort (VTD) by wind instrumentalists from Natal, Brazil.

METHOD:

Cross-sectional study with 117 professional musicians and music students from six official bands/orchestras in the city of Natal. Both the Vocal Tract Discomfort Scale and a sample characterization questionnaire were applied. The Chi-square test, Fisher’s exact test, and Mann-Whitney U test were applied in the statistical analysis of the variables.

RESULTS:

The most frequent and intense symptoms of VTD were sensitive throat and sore throat. There was a significant difference between the values of frequency and intensity of all symptoms both before and after playing the instrument. Dryness was the most intense symptom felt after playing the instrument. Musicians who report muscle pain and gastroesophageal reflux showed more VTD symptoms.

CONCLUSION:

Symptoms of VTD are experienced by wind instrumentalists and can be work-related since there was a difference in their perception after playing their instruments. There was also a relationship with gastroesophageal reflux and muscle pain, indicating that, in addition to collective issues, the individual musicians’ health should be taken into account.

Keywords

Music occupational health voice vocal tract discomfort

1 Introduction

The number of performing instrumentalists have grown in Brazil both intermittently and unsteadily, which is evidenced by fewer professionals with formal contracts and a high number of freelancers. Teaching in higher education and joining orchestras have been the main possibilities of formal work for professional musicians because, despite being highly qualified professionals, most have precarious employment relationships with no labor rights guaranteed [1]. Such reality in the professional music world may generate losses in the physical, psychological, and cognitive dimensions, strongly impacting the health of these workers [2].

Musicians are exposed to occupational stressors daily, which can result in multiple health problems [3]. These problems can affect their muscles, joints, ears, and vocal folds [4], as well as affect not only their performance at work but also their source of livelihood [3]. Such issues create different consequences for professionals depending on the size, weight, and type of instrument they play, as well as hours of dedication, exposure to noise, and sound pressure [4].

Wind instrumentalists may present vocal complaints due to the larynx activity while they are playing their wind instruments [5 –7] due to glottal constriction and opening in the airflow control [7], which may cause laryngeal symptoms. There may be vocal complaints such as hoarseness, throat clearing, and vocal failures after intense use of their instruments, which may be related to inappropriate daily voice use and vocal habits, or yet associated with other factors such as a heavy workload [8].

These professionals may suffer from vocal tract discomfort (VTD) in different frequency and intensity, interfering with the voice-related quality of life, as shown by Capellaro and Beber [9], who also recommend the importance of further research in this population. Due to the risk of work-related illnesses for this group of professionals, it is necessary to investigate the relationships between VTD and work-related activity.

This study aims to analyze the perception of VTD regarding work and health characteristics of wind instrumentalists from Natal.

2 Method

This is an observational, quantitative cross-sectional study approved by the Federal University of Rio Grande do Norte’s Human Research Ethics Committee according to the Certificate of Presentation for Ethical Consideration (CAAE) protocol no. 82301918.3.0000.5292 of February 27th, 2018, under Brazil’s National Health Council Resolution 466 of December 12th, 2012. Data collections were performed from April to June 2018 by a voice-specialized researcher.

The study population consisted of wind instrumentalists, both professionals or in training, who are members of official orchestras and bands in the city of Natal, Brazil. From the 64% prevalence of VTD in musicians [10], 95% confidence interval, 25% non-response rate, and a 10% margin of error, the sample had 117 musicians.

The study included individuals aged 18 years or over, who work as wind instrumentalists, both as professionals or in training, regardless of their instrument. Individuals with a history of laryngeal diseases were excluded. Individuals with allergies or the flu on the interview day were recruited later. Of the eight official bodies in the state of Rio Grande do Norte, six agreed to participate in the research, namely the Rio Grande do Norte State Symphony Orchestra (OSERN), the Federal University of Rio Grande do Norte’s Philharmonic Orchestra (OFUFRN), the Rio Grande do Norte Military Police Music Band (BMPMRN), the Symphonic Band of the City of Natal (BSCN), the Big Band Jerimum Jazz of the UFRN Music School (BBJJ), and the Aeronautical Music Band (ALA 10). The bands/orchestras were split into four groups: Aeronautical, UFRN (BBJJ/OFUFRN), Military Police, and the joining of musicians from OSERN/BSCN. The Big Band and the UFRN Philharmonic Orchestra musicians were grouped because they belong to the same institution. The participant selection process was performed through stratified sampling, in which each band group contributed to the proportional composition of the final sample.

Based on the assessment availability indicated by the conductors, musicians were recruited randomly at every rehearsal to read and sign the informed consent form and fill out a structured questionnaire. This aimed to identify sociodemographic (age, gender, education, time of service, and workload), vocal health-related (warm-up and cool-down, hydration, smoking, and referred diagnosis of respiratory tract diseases), and work history (time of occupation, type of employment bond, time of instrument practice, and other work activities) variables. The Vocal Tract Discomfort Scale (VTDS) was applied before the tests and after a minimum period of one hour of instrument playing [11] to identify both the frequency and intensity of VTD symptoms. The VTDS has eight categories for symptoms or sensations that can be felt in the throat (burning throat, tightness in throat, dry throat, sore throat, itchy throat, sensitive throat, throat irritation, and globus sensation). The subjects classify them on a scale of frequency, from 0 (never) to 6 (always), and intensity, from none to extreme. The symptom/sensation presence or absence was determined by using the cutoff point indicated by the literature: a) frequency: 0.5 for burning throat, tightness in throat, sore throat, itchy throat, and sensitive throat; and 2.5 for dry throat, throat irritation and globus sensation [12, 13]; b) intensity: 0.5 for tightness in throat, sore throat, itchy throat, sensitive throat; 1.5 for burning throat and globus sensation; and 2.5 for dry throat and throat irritation [12]. Values that were equal or greater than the cutoff point indicate symptom/sensation presence.

The Kolmogorov-Smirnov test found that the data did not have a normal distribution, so non-parametric tests were applied. Frequency and intensity analysis of the symptoms reported before and after playing the instrument was performed by using the Chi-square and Fisher’s exact tests. The number of symptoms reported by the musicians before and after playing the instruments and their relationship with the other variables was analyzed by using the Wilcoxon, Mann-Whitney U, and Kruskal-Wallis tests. All tests considered a 95% confidence interval.

3 Results

Of the 117 instrumentalists, the highest percentage was male (95%); with an average age of 35.6 years; high school and higher education (83%); statutory employment under the Brazilian labor law (73.5%); an average monthly income of 920 dollars; and an average workload of 40 hours per week, distributed evenly among the four groups of Natal orchestras. Most musicians play the clarinet, the saxophone, the trombone, and the trumpet. Of the total musicians, 44.4% reported not drinking coffee, 14.5% not drinking water frequently, 83.8% not drinking alcohol, 19.7% reported gastroesophageal reflux, 6% were smokers or had already smoked, and 31.6% had respiratory allergies.

Among the signs of VTD, the most reported before playing their instrument were sensitive throat, itchy throat, and sore throat, which are also the most intense symptoms. After playing the instrument, the most frequent and intense symptoms were sensitive throat, sore throat, and dry throat. There was a difference between the frequency and intensity of all symptoms before and after playing the instrument (Table 1).

Table 1
Presence of vocal tract discomfort symptoms in the VTDS of musicians who are wind instrumentalists in official bands and orchestras before and after playing the instrument. Natal, 2018

Symptom Frequency before Frequency after P-value

Presence n (%) Absence n (%) Standard deviation Presence n (%) Absence n (%) Standard deviation

Burning throat 24 (20.5) 93 (19.5) 0.408 31 (26.5) 86 (73.5) 0.443 <0.001

Tightness in throat 21 (17.9) 96 (82.1) 0.378 29 (24.8) 88 (75.2) 0.434 <0.001

Dryness 20 (17.1) 97 (82.9) 0.358 35 (29.9) 82 (70.1) 0.460 <0.001

Sore throat 31 (26.5) 86 (73.5) 0.443 33 (28.2) 84 (71.8) 0.452 <0.001

Itchy throat 33 (28.2) 84 (71.8) 0.452 32 (27.4) 85 (72.6) 0.448 <0.001

Sensitive throat 36 (30.8) 81 (69.2) 0.464 37 (31.6) 80 (68.4) 0.467 <0.001

Throat irritation 15 (12.8) 102 (87.2) 0.336 17 (14.5) 100 (85.5) 0.345 <0.001^*

Globus sensation 9 (7.7) 108 (92.3) 0.268 9 (7.7) 108 (92.3) 0.268 <0.001^*

Symptom Intensity before Intensity after P-value

Presence n (%) Absence n (%) Standard deviation Presence n (%) Absence n (%) Standard deviation

Burning throat 21 (17.9) 96 (82.1) 0.385 24 (20.5) 93 (79.5) 0.406 <0.001^*

Tightness in throat 20 (17.1) 97 (82.9) 0.378 30 (25.6) 87 (74.4) 0.439 <0.001^*

Dry throat 23 (19.7) 94 (80.3) 0.399 39 (33.3) 78 (66.7) 0.473 <0.001

Sore throat 31 (26.5) 86 (73.5) 0.443 33 (28.2) 84 (71.8) 0.452 <0.001

Itchy throat 33 (28.2) 84 (71.8) 0.452 32 (27.4) 85 (72.6) 0.448 <0.001

Sensitive throat 36 (30.8) 81 (69.2) 0.464 37 (31.6) 80 (68.4) 0.467 <0.001

Throat irritation 17 (14.5) 100 (85.5) 0.354 18 (15.4) 99 (84.6) 0.362 <0.001^*

Globus sensation 13 (11.1) 104 (88.9) 0.316 12 (10.3) 105 (89.7) 0.305 <0.001^*

Symptom	Frequency before	Frequency after	P-value
Burning throat	24 (20.5)	93 (19.5)	0.408	31 (26.5)	86 (73.5)	0.443	<0.001
Tightness in throat	21 (17.9)	96 (82.1)	0.378	29 (24.8)	88 (75.2)	0.434	<0.001
Dryness	20 (17.1)	97 (82.9)	0.358	35 (29.9)	82 (70.1)	0.460	<0.001
Sore throat	31 (26.5)	86 (73.5)	0.443	33 (28.2)	84 (71.8)	0.452	<0.001
Itchy throat	33 (28.2)	84 (71.8)	0.452	32 (27.4)	85 (72.6)	0.448	<0.001
Sensitive throat	36 (30.8)	81 (69.2)	0.464	37 (31.6)	80 (68.4)	0.467	<0.001
Throat irritation	15 (12.8)	102 (87.2)	0.336	17 (14.5)	100 (85.5)	0.345	<0.001^*
Globus sensation	9 (7.7)	108 (92.3)	0.268	9 (7.7)	108 (92.3)	0.268	<0.001^*
Symptom	Intensity before	Intensity after	P-value
	Presence n (%)	Absence n (%)	Standard deviation	Presence n (%)	Absence n (%)	Standard deviation
Burning throat	21 (17.9)	96 (82.1)	0.385	24 (20.5)	93 (79.5)	0.406	<0.001^*
Tightness in throat	20 (17.1)	97 (82.9)	0.378	30 (25.6)	87 (74.4)	0.439	<0.001^*
Dry throat	23 (19.7)	94 (80.3)	0.399	39 (33.3)	78 (66.7)	0.473	<0.001
Sore throat	31 (26.5)	86 (73.5)	0.443	33 (28.2)	84 (71.8)	0.452	<0.001
Itchy throat	33 (28.2)	84 (71.8)	0.452	32 (27.4)	85 (72.6)	0.448	<0.001
Sensitive throat	36 (30.8)	81 (69.2)	0.464	37 (31.6)	80 (68.4)	0.467	<0.001
Throat irritation	17 (14.5)	100 (85.5)	0.354	18 (15.4)	99 (84.6)	0.362	<0.001^*
Globus sensation	13 (11.1)	104 (88.9)	0.316	12 (10.3)	105 (89.7)	0.305	<0.001^*

Fisher’s exact – field with expected value <5.

No differences were found when comparing the categories of sociodemographic and work-related variables with the number of symptoms before and after playing the instrument (Table 2). Such an analysis of vocal health variables found that the number of symptoms reported before and after playing the instrument differed between those who had or those who did not have muscle pain and gastroesophageal reflux (Table 3).

Table 2

Comparison between the number of vocal tract discomfort symptoms in the VTDS before and after playing the instruments and the wind instrumentalists’ social-demographic variables. Natal, 2018

Variables	Categories	N (%)	Median before (interquartile distance)	p	Median after (interquartile distance)	p
Band	Aeronautics	37 (31.6)	1 (4)	0.205	1 (3)	0.256
	UFRN (BB/EM)	19 (16.2)	1 (2)		2 (2)
	Military Police	32 (27.4)	0 (1)		1 (2)
	OSERN/City Council	29 (24.8)	1 (5)		1 (4)
Sex	Male	112 (95.7)	1 (3)	0.607	1 (3)	0.332
	Female	5 (4.3)	0 (4)		0 (3)
Age	18–34 years old	45 (38.5)	1 (3)	0.238	1 (3)	0.303
	≥35 years old	72 (61.5)	0 (3)		1 (3)
Education	Illiterate/complete or incomplete elementary school	7 (6.0)	0 (2)	0.446	0 (2)	0.194
	Secondary school	47 (40.2)	0 (2)		1 (3)
	Higher education	50 (42.7)	1 (3)		1 (4)
	Graduate studies	13 (11.1)	1 (3)		2 (3)
Income	Up to 4 minimum wages	54 (46.2)	1 (3)	0.345	1 (3)	0.262
	>4 minimum wages	63 (53.8)	0 (2)		1 (3)
Knows the Association of the Musicians of Brazil (OMB)	No	63 (53.8)	1 (3)	0.535	1 (3)	0.382
	Yes	54 (46.2)	0 (3)		1 (3)

P < 0.05 – Mann-Whitney U test, Kruskal–Wallis test.

Table 3

Comparison between the number of vocal tract discomfort symptoms in VTDS before and after playing the instrument and the wind instrumentalists’ vocal health. Natal, 2018

Variables	Categories	N (%)	Median before (interquartile distance)	p	Median after (interquartile distance)	p
Feels muscle pain	Yes	45 (38.5)	2 (5)	<0.001	2 (4)	0.001
	No	72 (61.5)	0 (2)		1 (2)
Drinks coffee	Yes	65 (55.6)	0 (3)	0.267	1 (3)	0.928
	No	52 (44.4)	1 (3)		1 (3)
Drinks water	Yes	100 (85.5)	1 (3)	0.473	1 (3)	0.816
	No	17 (14.5)	1 (3)		1 (3)
Drinks alcohol	Yes	19 (16.2)	0 (2)	0.599	2 (3)	0.362
	No	93 (83.8)	1 (3)		1 (3)
Has reflux	Yes	23 (19.7)	3 (5)	0.003	3 (4)	0.001
	No	94 (80.3)	0 (2)		1 (2)
Smoking habits	Smoker/former smoker	7 (6.0)	0 (3)	0.836	0 (4)	0.668
	Does not smoke	110 (94.0)	1 (3)		1 (3)
Has respiratory allergy	Yes	37 (31.6)	2 (3)	0.016	2 (5)	0.014
	No	80 (68.4)	0 (2)		1 (2)

P < 0.05 – Mann-Whitney U test.

4 Discussion

The main findings of this study include a high frequency of VTD symptoms among wind instrumentalists in the city of Natal, with a higher frequency of symptoms in musicians who report experiencing muscle pain and gastroesophageal reflux. Dry throat and sensitive throat were the most frequent and intense symptoms after playing the instrument.

VTD can provide valuable information for the investigation of vocal health care, especially for workers who use their voices professionally [14]. Although wind instrumentalists do not use their vocal tract as much as a voice professional, several laryngeal structures are needed for producing sound and the vocal folds move intensely [15, 16], which justifies the presence of VTD in that population. Besides, previous studies show that wind instrumentalists have more vocal symptoms than musicians from other groups of instruments when compared to a control group. Due to these and other factors, Ecley [5] suggests that these professionals be included in the group of voice professionals.

In this study, “dry throat” was the most intense symptom after playing the instrument and the second most frequently reported symptom in the sample, showing a relationship between the increase in its frequency and intensity after playing the instrument. The vocal tract dryness sensation can have different physiological causes and can also be caused by climatic and environmental conditions [14]. It is also essential to consider the oral breathing technique when playing the instrument, which can cause dehydration of the entire vocal tract according to studies on oral breathing/xerostomia and vocal function [18]. Besides, each instrumentalist’s health conditions may also interfere, such as those who have respiratory allergies, who usually have changes in their breathing pattern to predominantly oral breathing [19], which worsens the dry throat sensation.

Our findings show there was a difference between frequency and intensity of all symptoms before and after playing the instrument. Despite not being the most frequent and most intense symptom, “tightness in throat,” for example, showed a statistically significant difference in the comparison between before and after playing the instrument. The presence of this symptom may be justified by pharyngeal contraction and relaxation movements due to the excessive pressure that the exhaled air exerts on the vocal tract [20], and also due to the firm velopharyngeal closure which directs the air to the oral cavity [21].

From these findings, we highlight that this population deserves attention since diseases and health issues arising from working conditions significantly impact their daily lives [22]. Also, the global plan of action on workers’ health argues that the workplace should not be harmful to the worker’s health and well-being, but rather serve as a setting for essential public health and health promotion interventions [23].

In our sample, there was a relationship between the number of VTD symptoms in wind instrumentalists who felt muscle pain and reported gastroesophageal reflux. Regarding muscle pain, research on professional orchestra musicians suggests that there is a higher prevalence of pain among string instrumentalists, but it is more intense in wind instrumentalists [24]. These professionals spend several hours in non-physiological postures, performing repetitive movements and making a great physical effort. Also, cervical region pain has been reported in several studies on wind instrumentalists [9 , 26] and may be related to the active participation of intrinsic and extrinsic muscles of the larynx, which is recruited during the execution of the instrument and can lead to more considerable VTD [14]. Besides, factors such as posture, the test environment, and the type of instrument may contribute to the intensity or onset of muscle pain [25, 26]. Jacukowics’ study [27] points out that some psychosocial aspects of work, e.g. long hours at work, work content, high job demands, low control/influence, lack of social support, were related to musculoskeletal pain.

When referring to the symptoms of gastroesophageal reflux, the study by Cammarota et al. [28] points out that the wind instrumentalists report a prevalence of typical reflux symptoms higher than other players. Playing a wind instrument leads to an abrupt, prolonged increase in intra-abdominal pressure, deep inspiration, and physical effort. Repeating that several times a day over years of professional activity can interfere with the function of the diaphragmatic sphincter, increasing the occurrence of reflux symptoms [28]. When gastric contents reach the laryngopharyngeal area, it can cause acid burns in laryngeal structures, affect physiology, and bring discomfort symptoms. If there is any prior damage to the vocal fold, the presence of acid in that region or poor vocal use can cause further damage or interfere with therapy [29].

Regarding allergies, a literature review indicated that the role of such pathology in vocal production has been poorly investigated, and further research on this common condition is needed [30]. However, some common issues in allergies, such as mucus hypersecretion and tissue edema, which can interfere with vocal fold vibration, as well as coughing and throat clearing, decreased expiratory volume with consequent insufficient subglottic pressure [30], pharyngeal globus sensation [31], and also the possibility of auditory impact, can interfere in the performance of the musicians’ professional activity.

Despite the values very close to significance for musicians who report respiratory allergies, the results did not reveal any statistical difference for this symptom. These results differ from the study by Rheder [32], which linked changes in the upper airways resulting from allergies to greater laryngeal effort as a compensatory mechanism. Besides, other pieces of research show that maybe playing wind instruments can aggravate an unknown vocal issue [28]. These data reveal how important it is to consider the musicians’ health aspects, which may be related to individual issues, routine, and work environment.

We can also highlight that sensitive throat and sore throat symptoms are among the most frequent and intense symptoms before and after playing the instrument. Overall, sensitive throat and throat irritation symptoms may be related to dryness or overload of the vocal tract. The use of inadequate strategies and the lack of appropriate options to deal with risk factors can contribute to the maintenance of symptoms or the onset of health disorders [33]. Therefore, musicians can benefit from vocal hygiene habits such as increased water intake as well as warm-up and cool-down [9]. Studies included in the literature review on spoken voice warm-up and cool-down are in agreement on the importance of its application due to the need for favorable muscle conditioning for vocal tract function [34]. The sample of this study, however, found no significant differences in this variable.

It is important to mention that our study has limitations. The diversity on compositions of professional groups and the different realities among the musicians’ routines in different institutions must be taken into account.

Furthermore, it is known that adjustments in the vocal tract can vary according to the type and technique of the instrument. In addition to being a limitation in the study, the adjustments made by each type of instrument point to the need for more primary studies by categories. This diversity limits the external validity in generalizing the results to other populations, however shows that other studies should be focused on VTD of wind instrumentalists, studying different work categories.

It is also possible that the VTDS was not sensitive nor specific to detect symptoms in this population since it was not developed and validated for them. Despite this, care in recruitment strategies, data collection and analysis, sample size, and inclusion criteria were carefully planned, thus increasing the internal and external validity of the study and highlighting essential aspects of wind instrumentalists’ vocal health.

5 Conclusion

In our study, symptoms of VTD are experienced by wind instrumentalists and can be work-related since there was a difference in their perception of all of the scale symptoms after playing their instruments. Sensitive throat and sore throat were the most frequent symptoms, and dry throat was the most intense symptom after playing the instrument. The number of symptoms was higher among musicians who reported muscle pain and reflux. These results highlight the need for health education actions for these professionals taking into account collective and individual health issues as well as working conditions.

Conflict of interest

The authors declare that there is no conflict of interest in this study.

Funding

This study was financed by the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES) - financing code 001.

References

Segnini

LRP

. O que permanece quando tudo muda? Precariedade e vulnerabilidade do trabalho na perspectiva sociológica. Cad CRH. 2011;24:71–88. https://doi.org/10.1590/S0103-49792011000400006

Barbar

AEM

, Crippa

JAS

, Osório

. Performance anxiety in Brazilian musicians: Prevalence and association with psychopathology indicators. Journal of Affective Disorders. 2014;152:381–6. doi: 10.1016/j.jad.2013.09.041

Dommerholt

. Performing arts medicine: Instrumentalist musicians. Part I General considerations. Journal of Bodywork and Movement Therapies. 2009;13:311–9. doi: 10.1016/j.jbmt.2009.02.003

Barata

. Doenças ocupacionais afetam saúde dos músicos. Cienc Cult. 2002;54:13–13.

Eckley

. Configuração Glótica em tocadores de instrumento de sopro. Revista Brasileira de Otorrinolaringologia. 2006;72:45–7. https://doi.org/10.1590/S0034-72992006000100008

Weikert

, Their

. Laryngeal movements in saxophone playing: Video-endoscopic investigations with saxophone player. J Voice. 1999;13:265–73. doi: 10.1016/s0892-1997(99)80031-9

Silvério

KCA

, et al. Avaliação vocal e cervicoescapular em militares instrumentistas de sopro. Rev Soc Bras Fonoaudiol. 2010;15:497–504. https://doi.org/10.1590/S1516-80342010000400005

Falchetti

. Comportamento vocal em músicos de sopro: Uma revisão de literatura. [monografia]. Florianópolis: Universidade Federal de Santa Catarina; 2014.

Capellaro

, Beber

. Vocal tract discomfort and voice related quality of life in wind instrumentalists. Jornal of Voice. 2018;32:314–8. doi: 10.1016/j.jvoice.2017.05.011

10.

Ferreira

APS

. Avaliação da qualidade vocal de militares instrumentistas de sopro da banda de música da polícia militar do Paraná e comparação antes e após ensaio. Dissertação de Mestrado. Universidade Tuiuti do Paraná, Curitiba, 2010.

11.

Mathieson

, et al. Laryngeal manual therapy: A preliminary study to examine its treatment effects in the management of muscle tension dysphonia. Jornal of Voice. 2009;23:353–66. doi: 10.1016/j.jvoice.2007.10.002

12.

Rodrigues

, Zambon

, Mathieson

, Behlau

. Vocal tract discomfort in teachers: Its relationship to self-reported voice disorders. J Voice. 2013;27:473–80. doi: 10.1016/j.jvoice.2013.01.005

13.

Lopes

, et al. Vocal tract discomfort symptoms in patients with different voice disorders. Journal of Voice. 2015;29(3):317–23. https://doi.org/10.1016/j.jvoice.2014.07.013

14.

Penteado

, et al. Vocal discomfort, signs and symptoms in soccer coaches and physical trainers. Distúrbios Comun. 2015;27:778–88. https://doi.org/10.1590/2317-1782/20152015021

15.

Gallivan

, Eitnier

. Vocal fold polyp in professional brass/wind instrumentalist and singer. J Voice. 2006;20:15–164. doi: 10.1016/j.jvoice.2004.11.006

16.

Chapman

. A strategy for proper utilization of the glottis and implications of improper use in trumpet performance. Open Access Dissertations. Paper 1188; 2014.

17.

Tuhanioglu

, Erkan

. Assessment of the effect of wind instruments on voice quality. KBB-Forum. 2018;17:131–7.

18.

Roh

, Kim

. The effect of acute xerostomia on vocal function. Arch Otolaryngol Head Neck Surg. 2006;132:542–6. doi: 10.1001/archotol.132.5.542

19.

Menezes

, Leal

, Pessoa

, Pontes

RMES

. Prevalência e fatores associados à respiração oral em escolares participantes do projeto Santo Amaro – Recife. Rev Bras Otorrinolaringol. 2006;72:394–9. https://doi.org/10.1590/S0034-72992006000300017

20.

Mukai

. Laryngeal movements during wind instrument play. Nippon Jibiinkoka Gakkai Kaiho. 1989;92:260–70.

21.

Kahane

, et al. Videofluoroscopic and laryngoscopic evaluation of the upper airway and larynx of professional bassoon players. Journal of Voice. 2006;20:297–307. doi: 10.1016/j.jvoice.2005.03.003

22.

Filho

. Perfil Epidemiológico dos trabalhadores. Revista Brasileira de Medicina do Trabalhador. 2004;2:103–17.

23.

World and Health Organization. Worker’s health: Global plan of action 2007. Disponívelem: https://www.who.int/occupational_health/WHO_health_assembly_en_web.pdf 455 Acesso em : 10 Out. 2018.

24.

Sousa

, et al. Playing-related musculoskeletal disorders of professional orchestra musicians from the north of portugal: Comparing string and wind musicians. Acta Med Port. 2017;30:302–6. doi: 10.20344/am7568

25.

Silva

, Lã

FMB

, Afreixo

. Pain prevalence in instrumental musicians: A systematic review. Medical Problems of Performing Artists. 2015;30:8–19. doi: 10.21091/mppa.2015.1002

26.

Lonsdale

, Boon

. Playing – Related health problems among instrumental music students at a University in Malaysia. Medical Problems of Performing Artists. 2016;31:151–9. doi: 10.21091/mppa.2016.3028

27.

Jacukowicz

. Psychosocial work aspects, stress and musculoskeletal pain among musicians. A systematic review in search of correlates and predictors of playing-related pain. Work. 2016;54:657–68. doi: 10.3233/WOR-162323

28.

Cammarota

, Masala

, Cianci

, et al. Reflux symptoms in wind instrument players. Aliment Pharmacol Ther. 2010;31:593–600. doi: 10.1111/j.1365-2036.2009.04208

29.

Trollinger

, Sataloff

. It’s all about the voice. .. for wind instrumentalists, too! Music Educators Journal. 2018:36–42. doi: 10.1177/0027432118803430

30.

Spantideas

, et al. The role of allergy in phonation. Journal of Voice. 2018:1–9. https://doi.org/10.1016/j.jvoice.2018.02.016

31.

Simberg

, et al. Vocal symptoms and allergy: A pilot study. Journal of Voice. 2009;23:136–9.https://doi.org/10.1016/j.jvoice.2007.03.010

32.

Rehder

. Inter-relações entre voz e motricidade oral. In: Ferreira

, Befi-Lopes

, Limongi

SCO

, organizadores. Tratado de fonoaudiologia. São Paulo: Roca; 2004, pp. 59–64.

33.

Lima

, Pinheiro

TMM

, Dias

, Andrade

. Development and prevention of work related disorders in a sample of Brazilian violinists. Work. 2015;51(2015):273–80. doi: 10.3233/WOR.141904

34.

Ribeiro

, Frigo

, Bastilha

, Cielo

. Vocal warm-up and cool-down: Systematic review. Rev CEFAC. 2016;18:1456–65. https://doi.org/10.1590/1982-0216201618617215