Braz. j. . vol.81 número2

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

REVIEW

ARTICLE

Work-related

voice

disorder

夽,夽夽

Paulo

Eduardo

Przysiezny

∗

_,

_Luciana

_Tironi

_Sanson

_Przysiezny

HospitalAngelinaCaron,CampinaGrandedoSul,Paraná,PR,Brazil

Received8February2014;accepted23March2014 Availableonline23October2014

KEYWORDS

Dysphonia;

Legislationastopic; Occupational medicine

Abstract

Introduction:Dysphoniaisthemainsymptomofthedisordersoforalcommunication.However, voicedisordersalso presentwithothersymptomssuchasdifficultyinmaintainingthevoice (asthenia),vocalfatigue,variationinhabitualvocalfundamentalfrequency,hoarseness,lack ofvocalvolumeandprojection,lossofvocalefficiency,andweaknesswhenspeaking.There areseveralproposalsfortheetiologicclassificationofdysphonia:functional,organofunctional, organic,andwork-relatedvoicedisorder(WRVD).

Objective:ToconductaliteraturereviewonWRVDandonthecurrentBrazilianlabor legisla-tion.

Methods:ThiswasareviewarticlewithbibliographicalresearchconductedonthePubMedand Biremedatabases,usingtheterms‘‘work-relatedvoicedisorder’’,‘‘occupationaldysphonia’’, ‘‘dysphoniaandlaborlegislation’’,andareviewoflaborandsocialsecurityrelevantlaws.

Conclusion:WRVDisasituationthatfrequentlyislistedasareasonforworkabsenteeism, func-tionalrehabilitation,orforprolongedabsencefromwork.Currently,forensicphysicianshave nocomparativeparameterstohelpwiththeanalysisofvocaldisorders.Incertainsituations WRVDmaycause,workdisability.Thisdisordermaybelabor-related,orbeanadjuvantfactor towork-relateddiseases.

PALAVRAS-CHAVE

Disfonia; Legislac¸ãocomo assunto;

Medicinadotrabalho

Distúrbiodevozrelacionadoaotrabalho

Resumo

Introdução:Adisfoniaéoprincipalsintomadedistúrbiodacomunicaçãooral;noentantoos distúrbiosdavozmanifestam-sealémdoquadrodisfônico,comdificuldadeemmanteravoz (astenia),cansaçoaofalar,variaçãonafrequênciafundamentalhabitualvocal,rouquidão,falta

夽

Pleasecitethisarticleas:PrzysieznyPE,PrzysieznyLT.Work-relatedvoicedisorder.BrazJOtorhinolaryngol.2015;81:202---11.

夽夽

Institution:HospitalAngelinaCaron,CampinaGrandedoSul,Paraná,PR,Brazil.

∗_{Corresponding}_author.

E-mail:pauloorl@hotmail.com(P.E.Przysiezny). http://dx.doi.org/10.1016/j.bjorl.2014.03.003

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devolumeeprojec¸ãovocal,perdadaeficiênciavocalepoucaresistênciaaofalar.Váriassão aspropostasdeclassificac¸ãoetiológicadasdisfonias:funcional,organofuncional,orgânicae distúrbiodevozrelacionadoaotrabalho(DVRT).

Objetivo: Realizarumarevisão deliteraturasobreDVRT ealegislac¸ãotrabalhistabrasileira vigente.

Método: Artigoderevisãocompesquisabibliográficarealizadanainternet,nossitesPubmed eBireme,comostermos‘‘distúrbiodevozrelacionadoaotrabalho’’,‘‘disfoniaocupacional’’, ‘‘disfoniaelegislac¸ãotrabalhista’’,alémderevisãodalegislac¸ãotrabalhistaeprevidenciária pertinente.

Conclusão:DVRT éumasituaçãoqueatualmentesemostrafrequente,tanto comocausade absenteísmooureabilitaçãofuncional, comodeafastamentoprolongadodotrabalho. Atual-mente, omédico peritonão encontraparâmetroscomparativos objetivosque direcionema análisepericialemdistúrbiosvocais.DVRTpodecausar,emdeterminadassituações, incapaci-dadelaboral,emuitasvezes,atuarcomoumfatoradjuvanteouestardiretamenterelacionado adoençasdotrabalho.

Introduction

The voiceisan essential toolinthelives ofmany profes-sionals,withapproximately25%oftheeconomicallyactive populationconsideringtheirvoicetobeacriticalinstrument oftheirjob.1

The concept of ‘‘normalvoice’’ iscomplex, andthere is noconsensuson thesubject. Thereis not a patternof ‘‘normalvoice’’,i.e.,therearenodefinedlimitsofwhatis considerednormal,andfromwhichpointitcanbesaidthat anindividualhasdysphonia.2

Whenthevoicechangesnegatively,itissaidthatitis dis-turbedordysphonic.3_Dysphonia,_therefore,_can_be_defined asanydifficultyor changeinvocal emissionthatdoes not allowforanaturalvoiceproduction,4,5_preventing momen-tary or permanent oral communication.6 _Thus, _dysphonia causesdamagetotheindividual,sincethevoiceproduced exhibitsdifficultiesor limitationsin fulfillingitsbasic role oftransmissionofverbalandemotionalmessage.5

Dysphoniaisasymptom,notadisease;itisa manifesta-tionthatispartofthespeechdisorderpicture.2_Dysphonia isthemain symptomoftheoral communicationdisorder.5 However,voicedisordersaremanifestedbeyondthe dyspho-nicpicture;thepatientmayexperiencedifficultyinkeeping his/hervoice(asthenia),vocal fatigue,variationin habit-ualfundamentalvocalfrequency,hoarseness,lackofvocal volume and projection, loss of vocal efficiency, and low resistancewhenspeaking.6

Thus,allcasesofdysphoniaconstituteavoicelimitation; this problem can be classified into one of four levels of intensity. The first is a mild degree, characterized by an eventual or almost imperceptible dysphonia. The worker canperformtheirusualvocalactivitieswithminimum dif-ficulty,littlefatigueandwithnointerruption.Thesecond is a moderate degree, characterized by a continuously perceived dysphonia; the voice is audible, presenting oscillations; the usual vocal activities are possible, there isaneffort(perceivedbyhim/herselforbytheaudience), showingfailure,eventualorfrequentfatigue,andtheneed for interruptions. The intense degree is characterized by

constant dysphonia; it becomes difficult to hear his/her voice; the patient cannot perform his/her activities, or doing so causes great effort, intense fatigue, and major interruptions. Finally, the extreme degree, or aphonia, is characterized by the ‘‘near absence’’or ‘‘total lack’’ of voice; the voice becomes inaudible, demanding written communicationorgesturesforthepersontobeunderstood; theworkercannotperformhis/heractivities.5

Despitebeingoneofthemainformsofhumanexpression andof beinguseddailybymost people,thereisaspecial groupofindividuals thatpresent high vocal demand7_:_the voiceprofessionals,includingsingers,teachers, telemarket-ingoperators,lawyers,clergymen,consultants, salesmen, andhealthcareproviders.7

Conceptually, the professional voice is defined as the formoforalcommunicationusedbyindividualswhodepend onitforafulloccupationalactivity.5_That_is,_to_characterize theprofessionaluseofthevoice,theindividualmustmake alivingthroughthevoice.8

Thereareseveralproposalsforanetiologicclassification of dysphonia. The most adopted classification consid-erssomebasic factors: functional,organo-functional,and organicdysphonia.9_To_improve_the_diagnosis_and_treatment ofvoicedisorders,amovementthatbringstogether differ-entinstitutionsinordertoclassifyanewcategoryofdisease, the work-related voice disorder (WRVD), is currently in progress.This movement aimstoanalyzethe relationship ofthesefactorswiththeenvironmentandtheorganization ofwork.8,10

TheaimofthisarticleistoreviewtheliteratureonWRVD andthecurrentBrazilianlaborlegislation.

Methods

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Literature

review

TheconceptofWRVD

WRVDis any formof vocal change directly relatedtothe use of voice during a professional activity that reduces, compromise,orpreventstheperformanceand/or communi-cationoftheworker,withorwithoutsomeorganicalteration ofthelarynx.11

WRVDismanifestedbyseveralsignsandsymptomsthat maybepresent, concurrentlyor not,varyingaccording to theseverity of the clinical presentation.8 _The _most com-monsymptomsare:fatiguewhenspeaking(vocalfatigue), hoarseness,dry throat/mouth,effort tospeak,voice fail-ure(‘‘breakingof thevoice’’), lossof voice,hawkingup, voiceinstabilityortremor,sorethroat/painwhentalking,a deepervoice,lackofvocalvolumeandprojection(‘‘weak voice’’),lossonvocalefficiency,lowresistancewhen speak-ing,ornecktension.7,8,12

Itisimportanttocharacterizesignsandsymptomswith regardstotheonset,duration,andimprovementand wors-eningfactors.8

Usually, the symptoms emerge insidiously.8 _In schoolteachers, vocal dysfunction arises later, after an average of 14 years of work.13 _Conversely, _{telemarketing} operatorsexhibitdysphoniaearlier,anditcan beinferred that emotional stress, environmental and organizational factors, and the profile of this functional category favor earlychanges.13 _It_is _worth _mentioning _that_physical edu-cation teachers exhibit a higher tendency of acute vocal dysfunction,due tothe use of abrupt vocal attacks with highintensity.13

Thesymptomsprevailattheendofaworkingdayorat theendoftheworkingweek;thesymptomatologydecreases afteranovernightrestorduringtheweekends.7,8_Gradually, thesymptomswillpresentthemselvescontinuouslyduring working hours or during the entire day, without recovery evenwithvoicerest.Atthisstage,theworkercan hardly exercisehis/hervocalfunctionwiththeexpectedefficiency, especiallyinepisodesofseveredysphonia.8

The WRVD presentation may also be associated with symptoms of psychological stress and mental suffering, faced with the demands of work organization. The need to respond to these demands, fear of unemployment, lack of information and other contingencies pertaining to the world of contemporary work lead the worker to endure these symptoms and continue working, until his/her condition worsens, necessitating a more complex treatment.8

Riskfactors

ThedevelopmentofWRVDismultifactorial;itisassociated withseveralfactorsthatcandirectlyorindirectlytriggeror worsentheworker’svoicealteration,andtheremaybean interactionofthesefactorsintheworkplace.Thatis,these factorsmayactaloneorincombinationforthedevelopment ofthevoicedisorder.

The aggravating and predisposingrisk factorsof WRVD canbegroupedasfollows:2

Riskfactorsofnon-occupationalnature

As in all health-disease processes, some individual char-acteristics may function as aggravating and/or triggering factors, such as age, female gender, inappropriate or excessive (extended) use of the voice, extra-professional activities with high vocal demand (leisure, or working a doubleshift),respiratoryallergies,upperrespiratorytract diseases,hormonalinfluences,medications,alcoholabuse, smoking, poor hydration, stress, and gastroesophageal reflux,amongothers.2

Riskfactorsofoccupationalnature

a. Organizational,pertinenttotheworkingprocess(nature of the organization of the working process):extended workdays,overload,accumulationofactivitiesor func-tions, excessive vocal demands, lack of breaks and of restingperiodsduringtheworkday,lackofautonomy,a stressfulworking pace(pressuretomeet targets), and dissatisfactionwithworkorremmuneration.2

b. Environmental(workenvironment):

(b.1) Physical hazards: high level of sound pressure; sudden change intemperature; inadequate envi-ronmentalventilation;inadequateluminosity.2 (b.2) Chemical hazards: exposure to upper

airway-irritating chemicals (solvents,metal fumes, poi-sonousgas);presenceofdustand/orsmokeinthe workplace.2

(b.3) Ergonomic risks due tothe lack of proper plan-ning in relation to furniture (implies postural changes), toequipment and material resources, tothe acousticenvironment, andtolack ofsafe drinkingwaterandaccesstotoilets.2,14

The voicedisordercan betriggered or exacerbated by an occupational vocal demand; therefore, it is necessary to establish the connection with the function or activity performance.2

Itis believed that the main triggering factor for occu-pationaldysphoniaisrelatedtooveruseofthevoice(vocal abuse).1 _{Professionals}_who _use_their _voices_are_subject_to aprocessoffrequent‘‘collision’’,duetorepetitive move-mentofthevocalfolds,causingtrauma(friction)ofthese vocalfolds,withappearanceofan acutelaryngeal inflam-matory process.1,15 _{Concurrently,} _there _is _tension _in _the vocalcords,usuallyasaresultofanincorrectcompensation incasesoflaryngitis,particularlyofviraletiology.1

Importantly,the lifestyleof these professionals (smok-ing,unhealthydietwithincreasedriskofpharyngolaryngeal reflux)alsoplaysanimportantroleinthegenesisofvocal disorders.1

DiagnosisofWRVD

For the diagnosis of WRVD, the following should be obtained:8

• Medical,occupational/working andepidemiological

his-tory.

• Clinical assessment (preferably performed by an ENT

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• Phonoaudiologicalassessmentofvoice.

• Occupationalsurvey:assessmentoftheconditionsandof

theenvironmentalandorganizationalriskfactorsofthe workspace.

• Surveyofrelevantbehaviorsandhabits.

Specifically, in the elaboration of a clinical and occu-pational history,it is essentialtoinvestigate indetail the clinicalaspectsofthedisease(signs,symptoms,and labo-ratorytests),aswellasaspectsrelatingtotheenvironment andworkroutine.8

The diagnosticimpressionshouldconsiderthe intersec-tionoftheabovedescribedsub-items,withspecialattention tooccupational history. It is important toremember that alladjuvanttestsshouldbeinterpretedinlightofclinical reasoning.8

The disease should be considered as of the occupa-tionaltypewhenthereisarelationshiptowork,evenwith concomitantfactorsnotrelatedtotheworkactivity.8_The principleofco-causalityunderliesthisassertion, consider-ingthepossibilityofcoexistenceofantecedent,concurrent, andsubsequent causes tothe voicedisorder, without this preventing the establishment of a relationship with the patient’swork.16

AnearlydiagnosisandprompttreatmentofWRVDenable abetterprognosis.Thisdependsonseveralfactors,suchas theworker’slevelofinformation,theeffectivenessofthe prevention program and medical control of the company, of itsmanagement,and theopportunity of the workerto expresshis/herhealthcomplaintswithoutsufferingexplicit orimplicitreprisals.8

WRVDtherapeutics

After a diagnosis of WRVD, treatment should be offered, whichmayinvolveamultidisciplinary teamconsistingof a physician,speechtherapist, physiotherapist,psychologist, andoccupationaltherapist.8

In assessing WRVD, all determinants of the worker’s health status should be included; if necessary, his/her treatment should focus onbiological, environmental, and personalityfactorchanges,andnotsimplyonthereduction oftheoccupationalvocalload.15

Thetreatmentandrehabilitationprogramshouldbe spe-cific to each case, seeking the recovery of the worker’s health.8

Obviously,treatmentdependsontheidentifiedetiology, withoptionsformedicalorsurgicaltreatment.When indi-cated,anysurgerymustbeperformed.However,mostvocal disordersareresolvedwithoutsurgicalintervention.7

Vocalspeechrehabilitationisoftenusedconcomitantly, andthisusuallyallowsforabettervocaladaptationandthe earlierreturnoftheworkertohis/herworkenvironment.

Commonly,inthepresenceofacaseofacutedysphonia, vocalhygieneandrestareindicated.

Vocalhygiene(vocalhealth)

Vocal hygieneencompasses a set of vocal preventive and curativemeasures,suchas:guidancebyaqualified profes-sionalabout the vocal functioning,avoidanceof smoking, avoidanceofalcohol abuse,avoidanceofinadequatebody

postures, treatment of infectious and allergic respira-torydiseases,adequatenutritionwithexcellenthydration, avoidance of dry air environments, avoidance of using medicationswithout prescription,andpracticeofphysical activities.

The patient should always increase significantly the waterintake,insmallsipsatroomtemperature.An exces-siveintakeofdairyproductsshouldbeavoided;thesefoods increase the production of mucus in the vocal tract and cause it to become thicker.7 _Singing _lessons _help _voice professionals.7

Vocalrest

Duringtreatment,thepatientmaycontinuetowork;if nec-essary,he/sheshouldbetemporarilyremovedfromhis/her duties, in order to not exacerbate the vocal problem or causeanyharmduringtheexerciseofhis/herfunction.This removalshouldbeconsideredasaworkleavecausedbyan occupationaldisease.Inthis case,theworkercan tempo-rarilybere-adaptedintoanotherfunction,inwhichtheuse ofthevoicedoesnotoccurasoften.Ifthere-adaptationis notpossible,theworkershouldbereferredtotheNational SocialSecurityInstitute(InstitutoNacionaldoSeguroSocial INSS)forapaidworkleave.8

Vocalrest,eitherrelativeorabsolute,isimportantinany typeoflaryngitis.Itshouldbesuggestedthattheworkernot onlyrestfromtheprofessionaloccupations,butalsofrom leisureactivities,asitisofteninsocialandleisureactivities thattheindividualcommitsgreatervocalabuse.7

Thevocalrestassociatedwithabsencefromworkimplies twosituationsthatcanpotentiallyimprovedysphonia.The firstsituationis theobvious reductionof inflammation by decreasing thefriction between the vocal folds. The sec-ondisassociatedwiththedecreaseofapossiblecondition ofoccupationalstress,whichcanresultinreductionofthe contractionwithmuscularrelaxation.

The timeof restis variable,depending ontheetiology andassociatedfactors.Usually,aworkleavenotexceeding seven dayssuffices, because the maintenance of working routineis required topromote anadequate adaptation to realworking conditions and for an effective treatment.13 Even in the case of a complete rest, a periodexceeding sevento10 daysshouldbegenerallyavoided, becauseof the risk of muscular atrophy.7 _In _general, _three _days _are sufficient.

Ortisetal.concludedthat,ifthevocalhygieneand treat-mentarefollowed properly, thepatientcan keep his/her workingpracticeduringthetreatmentperiodwithoutriskof worsening,sinceitisknownthatwhenthevoiceisadjusted, thereis noimpairmentofthe phonatoryorgan.Moreover, eveniftherearesmallstructuralchanges,theprofessional canperformtheinterventionswithout organicand phona-toryimpairment.13

Obviously,thisapproachcan,inprinciple,differfromthe prevailinglegallegislation,whichrecommendstheremoval oftheworkerfromriskagentswhenhe/shepresentsa dis-ease that wastriggered or is worsened by his/her work. However,inthe case of dysphoniaof occupational origin, thisrulemayoftenbeinadequate.13

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shorterrecoverytime,willcertainlyconstituteariskfactor foroccupationallaryngopathy.1

PreventivemeasuresforWRVD

Preventionpresupposestheidentificationofarisksituation totheworker’health.Theroleoftheoccupational physi-cian,aswell asoftheother membersof thehealthteam andof the insurance company, is criticalfor: the control of risk factors, the inclusion of the worker removal from theworkenvironment,appropriaterehabilitation,and func-tionalredeployment.8

Preventive measures should be adopted in the com-prehensive care of thevoice professional.13 _However,_the workerusuallyreceivesnoinformationaboutthe function-ing of the vocal folds in order to decrease the risk for dysphonia.13_It_is_observed_that_many_voice_{professionals}_do notreceivespecifictraining(vocaltechnique)oranytypeof orientationforsuchanintensiveuseofvoiceinoften unfa-vorablecircumstances,and arethus subjecttoinjury.7 _To makeananalogywithanyotherphysicalactivity,anathlete mustspendyearstrainingthespecific musclesinvolved in his/heractivity,aswellasundergocardiopulmonary prepa-rationinordertoattaingoodperformances;poorlytrained orphysicallyunpreparedathletesaresubjectedtoinjuries that are specific to their physical activity.7 _Just _as _the training of an athlete requires specific knowledge about thephysical activitypracticed, thecare ofthevoice pro-fessionalalsorequiresspecialknowledge.7_This _vocal_care is properlydisseminated between singers and artists,but unfortunatelythisisnottrueamongotherprofessionals.13

ConsideringthatWRVDhasgreatsocial,economic, pro-fessional,andpersonalimpact,itisessentialthatpreventive actions that may prevent the onset of this event are prioritized. Preventive measures include the adoption of protective andpreventive actions for vocal health, which mustmeet the specificitiesof thedifferent working envi-ronments.Amongthem,wecanmention:8

• Educationalandtherapeuticactionsofhealthpromotion

aimed at the proper use of the voice, through notions ofanatomyandphysiologyofthevocaltract,vocalcare (vocal hygiene), vocal warming and cooling down, and vocalexpressiveness.

• Identificationandreduction/eliminationofexistingvocal

health risks in the environment and/or work organiza-tion,andeducationalactivitiesaimedatpromotingvocal healthandvocalcomplaint/disorderprevention,suchas participation in an internal accident-prevention week, lectures,campaigns,workshops,andspecifictraining.

• Early identification of complaints and voice changes

throughmedicalassessmentandperiodicphonoaudiologic evaluation.

LaryngoscopyandWRVD

Videolaryngoscopycanrevealabnormalitiesfromalaryngitis irritationprocesswithedemaofthevocalfolds,tonodules, bleeding,andpolyps.12

Inlaryngoscopy studies,laryngitis (inflammation ofthe laryngealmucosa)isthemostcommonfinding.1

Thereisevidencethatvocalfoldnodulesarealso com-mon in voice professionals. However, there is a variety of other organic (polyps, Reinke’s edema) and functional changesinthelarynxandrespiratorytractthatcancause dysphonia.4

Itis important tonote that theclinical manifestations offunctionaldysphoniacanresultinlaryngoscopicstudies withnormallaryngealmorphology.17

Dysphoniaandlaborlegislation

Theprevalentepidemicsintheworkenvironmentare sub-ject tochanges,in asimilarwaytowhatoccurswiththe techniques of prevention,diagnosis, andprognosis.In the context of occupational health, the changes in the legal sphere regarding the recognition ofoccupational diseases mustalsobeincluded.18

The occupational use of the voice cannot be disre-gardedasacontributingfactortothedevelopmentofvocal dysfunction. However, the history, physical examination, laryngoscopicstudy,andtheperceptualvoiceanalysismust becarefullyassessedinordertoestablishtheirrelationship withwork.13

Laryngopathycanrelatetothelossoflaborcapacity,loss inqualityofwork,absenteeism,employees’s replacement andturnover,withfinanciallosstotheworker.12

Dysphoniais notlisted asanoccupational disease,and therearenoclearlyestablishedlegalrulesthatrelatevocal changewithwork.Thereisnodefinedstandardtoestablish thecausalrelationshipofdysphoniawithwork,whichmakes itextremelydifficulttorelatedysphoniadirectlytolabor.13 Sofar,therearethreespecificBrazilianlegislative situa-tionswithrespecttoWRVD.

The first situation is the Decree SIT/DSST No. 9, of March 30, 2007 (Official Gazette, April 2, 2007) approv-ing the AnnexII of NR-17 (Workand Telemarketing). This Annexestablishesrulesregardingfurniture,controlstation equipment (headset), and minimumenvironmental condi-tions(suchasnoiselevels,temperatureindex,windspeed, and relative humidity).It also determines that the work-ingtimeofeffectiveactivitymustbe,atmost,ofsixdaily hours,includingbreaks.19

Thesecond situationrelatestothe brilliantpioneering action, since2008,of theStateOfficeofHealthand Civil DefenseofthestateofRiodeJaneiro(SecretariaEstadual deSaúdeeDefesaCivildoEstadodoRiodeJaneiroSESDEC), whichrecognizesWRVDasapublichealthissue,establishing thatthisdiseaserequiresnotification.20

Finally,thethirdsituationisthemobilizationaimingthe elaborationof aprotocolfor WRVD.OnMarch16,2012, a publicconsultationforsuggestionsfortheelaborationofa WRVD protocolby the HealthSurveillance Office,through theDepartmentofEnvironmentalandOccupationalHealth (DepartamentodeSaúdeAmbientaleSaúdedoTrabalhador DSAST)wasconcluded.Todate,thisprotocolhasnotbeen officiallypublished.

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varioushospitals,duetotheirpathologicalneedtoplaythe sickrole.3_Commonly,_these_individuals_have_full_knowledge oflaborlawsandstopthesimulationwhenthesituationis nolongeradvantageous.3

Notification

Inrecentyears,therehasbeenaprogressiveincreaseinthe numberof professionals whouse theirvoice asaworking tool.Asadirectconsequence,ahigherincidenceofhealth problems relatedtothevoicecan beexpected.However, therearenoepidemiologicaldataonthemagnitudeofthis healthproblemintheBrazilianUnifiedHealthSystem (Sis-tema Único de Saúde SUS),since voice disorders are not includedinthelistofnotifiablediseasesfromtheBrazilian MinistryofHealth(DecreeGMNo.104/11).21

The notificationofthediseaseisfundamental,inorder tomeasureandqualifyitsdistributionandtoallowthe plan-ningofpreventiveandreliefactionstobeeffective.8

AlthoughtheBrazilianMinistryofHealthdoesnotinclude voicedisordersamongthecompulsorynotificationinjuries totheNationalInformationSystemforDiseaseNotifications (SistemaNacionaldeInformac¸õesdeAgravosdeNotificac¸ões SINAN), the municipalities and states can stimulate this reporting to other information systems of SUS.21 _Since December of 2008, the state of Rio de Janeiro, through SESDEC,tooktheleadershiptorecognize WRVDasa pub-lic healthissue.20 _The _Department_of_Health_of _that_state includedthesymptom‘‘dysphonia’’(CID10:R49.0)inthe SINANasofstateinterestfornotification.20

Communicationofwork-relatedaccidentforWRVD

WhenconsideringasuspecteddiagnosisofWRVD,aNoticeof OccupationalInjury(Comunicac¸ãodeAcidentedeTrabalho CAT)mustbeissued(NR-7,item7.4.8,1994).ACATshould beissuedevenincasesthatdonotentailworkingdisability, forrecordingpurposes,notnecessarilyforworkleaves.8

ThemedicalcertificateofCAToranequivalentmedical report should be completed by the company’s occupa-tionalphysician,assistantphysician(publicorprivatehealth service),orphysicianinchargeoftheMedicalControl Pro-gramforOccupationalHealth(ProgramadeControleMédico de Saúde Ocupacional PCMSO), containing, among other information, the occupational activity and working place description;dateoftheaccident;theprobabledurationof treatment;necessity,ornot,ofabsencefromworkfor treat-ment;adescriptionofthenatureoftheinjury;andprobable diagnosis.21

Casesofworseningorrecurrenceofdisabling symptoma-tologyshouldbeobjectofanewCAT.21

The CAT must besent by the company tothe INSS by thefirstbusinessdayafterthedateofincapacityonset,in ordertoestablishacausallink,adisabilityevaluation,anda definitionofthesocialsecurityconductrelatingtowork.In thosecasesinwhichthecommunicationisnotmadebythe company,thestatutoryterms/deadlineswillnotprevail.21

Once receiving the CAT, the social security benefits department at INSS will register the document, checking whetherallfieldswerefilled.Ifthefillingisincomplete,the CATmustbesubmittedtoacorrectfilling,withoutimpairing thesubsequentcompletionofmedicalevaluation.21

The accident will be technically characterized by the INSS’s medical evaluator (Article 337 of Decree No. 3.048/99),whowillconductatechnicalsurveyinorderto establishthecausalconnectionbetween:I---theaccident andtheinjury;II ---thediseaseandthework;andIII---the causeofdeathandtheaccident.21

No CAT may be refused; they must be recorded, for statisticalandepidemiologicalpurposes,regardless ofthe existenceofincapacityforwork.21

Ifthereisarecommendationofsickleaveofoverfifteen days,theemployerwillreferthepatienttoINSS’ medical assessmentforaforensicexamination, fromthesixteenth dayofsickleaveon.21

MedicalinspectionprocedureswithINSS

In a survey conducted by INSS in 2012, from January to November, 2,013,081 security benefits (type 31) were granted, and of these, 2622 were motivated by CATs related to voice disorders (IDCs: J04, J37, J38, R47, R48, R49) (0.13%). In the same period, 282,610 benefits were granted due to occupational accidents or diseases (type 91) and of these, 454 were for voice disorders (0.16%).22

Inthepresenceofavoicedisorder,variousprofessional groupsapplyfor sickleave duetotheinabilitytoperform theirfunctions.AsurveyconductedbytheWorker’sHealth DepartmentofthecityofSãoPaulofoundthatemployeesick leavesandfunctionalre-adaptationsduetovoicedisorders weremorefrequentamongprofessionalsinvolvedin teach-ing(teacher,childdevelopmentassistant,andeducational coordinator,amongothers).10

Duringtreatment,theworkercanstayonhis/herjobor, upontheneed,stepawaytemporarily.Thisshouldbe consid-eredasafunctionremovalduetoanoccupationaldisease.In thiscase,theworkercanbere-locatedintoanotherfunction inwhichthereisnoriskinusingthevoice.Ifthe redeploy-ment is not possible, and the time off-work needs tobe greaterthan15days,thepersonshouldbereferredtothe INSSforaworkleavewithfullpay.8

Accordingtolegalprovisions,theworkoftheSocial Secu-rity medical expert is to check the worker’s inability to work. This statement means that this professionalshould checkfor thepresenceof disease,understandthe profes-sionof the insuredperson (every workerwho contributes monthlytosocialsecurityiscalled‘‘insured’’,being enti-tledtothebenefitsandservicesofferedbyINSS),andhow his/herfunctionisexecuted(theseissuesincludea knowl-edgeoftheprofessionalprofile,registryoftheprofessionin theBrazilianlistofoccupations,andnotionsofhygieneand occupationalhealth).23

Toidentifythedisease,theINSSmedicalexpertmust con-siderthemedicalreportsoftheinsured,assesstheclinical features,riskfactorsofoccupationalandnon-occupational nature and, if necessary, request additional exams. The medical expert should request the cooperation from the physicianattendingtotheinsured.21

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Apart fromthe incapacity checking, it is also the role oftheINSS medicalexpert tocharacterizethis inability ---whetheritisofthesecuritytype,or accidental.Todoso, threeparametersaretakenintoaccount,besides theCAT itself:theProfessionalorLaboralTechnicalNexus(NTP/T), whichverifiestherelationshipbetweeninjuryandexposure accordingtothe Annexes ofDecree 6042/2007;the Tech-nicalEpidemiological Social SecurityNexus (NTEP), which crosses the occupational data with frequently associated diseases;andthe technicalnexusby diseasecomparedto work-relatedaccident,whichconstitutestheassessmentof themedicalexpertandhis/herconclusionwithrespectto theworkasacausalfactorofthediseasepresentedbythe insured.24

The conclusions of the medical expert regarding the assessment of working capacityand the establishment of thecausalnexusbetweeninjuryandwork,canresultinthe followingsituations:21

I Noworkingdisabilitywasobservedinanyoccasion;thus, thisisacaseofrejectingtherequiredsick-leavebenefit byaccident,regardlessofcausality.

II Anincapacitytoworkwasidentified,butacausal rela-tionshiphasnotbeenestablished;thesickleavebenefit isgranted(species31).

III A working disability exists, with an established causal nexus;the sick-leavebenefitby accidentis grantedas required(species91).

IncapacitybyWRVD

Although there is no specific legislation to regulate the careofthevocaltract,thisdoesnotexempttheemployer of the obligation to maintain the vocal health of voice professionals.12

Workingcapacityistherelationshipofbalancebetween thedemandsofagivenoccupationandtheabilitytoperform it.25

Dependingonthedegree of injuryandseverityof dys-phonia,thelaryngealdiseasesinduced bytheprofessional useofthevoicereducetheworkingcapacityoftheworker, i.e.,leadtoapartialortotaldisability.12

Incapacitytoworkistheimpossibilityofperformingthe specific tasks of an activity or occupation, as a result of morphopsychophysiological changes caused by disease or accident.26

Thepersonalrisktolifeortothirdparties,andalsothe riskofdeteriorationduetothepermanenceintheactivity, areimplicitlyincludedintheconceptofdisability,provided thattheyarepalpableandindisputable.26_A_classic_example ofthissituationisthatofabusdriverwho,afteranaccident ofanykind,developsuncontrolledseizures.Inthiscase,the busdrivercanendangerthelivesofthepassengers.27

Theexistenceofillnessorinjurydoesnotmeaninability. Severalcarriersofwell-defineddiseases(suchasdiabetes, hypertension,etc.) or injuries (sequelae of poliomyelitis, amputationofbodyparts)canandshouldwork.However,if aworseningoftheclinicalpictureoccurs(anatomic, func-tional, or mental), that hinders the development of the activity,thosenon-disablingdiseasesorinjuriescanbecome disabling.25

The concept of disability should be evaluated by its extentanddurationandbytheoccupationperformed:26,27

As itsdegree, the working disabilitymay be partialor total:

a. A partial disability is a degree of disability that still allowstheperformanceofactivitywithoutrisktolifeor furtherdeterioration,andiscompatiblewiththe approx-imate salary that the person received before his/her illnessoraccident.26,27

b. The disabilityis regardedastotal iftheincapacitation thatcreatesaninabilitytostayonthejobdoesnotallow fortheaverageincomeachievedundernormalconditions byworkersinthecategoryunderconsideration.26,27

Thedurationoftheworkingdisabilitymaybeof tempo-raryorofindefiniteduration(permanent):

a. A disability whose recovery can be expected within the foreseeablefuture is considered astemporary.26,27 Temporary disability disappears during treatment, by convalescenceorbytheconsolidationoflesions,without disablingorderogatorysequelae.

b. An indefinite (permanent) disabilitywill notchange in theforeseeablefuturewiththetherapyand rehabilita-tionresources availableat thetime.26,27 _This _disability arises from more severe accidents or diseases (and, therefore, leavingdisablingsequelaeaftertreatment), orfromsituationsthatarenotamenabletotreatment.28

Withrespecttoitsrelationtotheprofession,theworking disabilitymaybe:

a. Uniprofessional:thatinwhichthehindrancereachesonly aspecificactivity.26,27

b. Multiprofessional:thatinwhichthehindrancecovers var-iousprofessionalactivities.26,27

c. Omniprofessional:that implies the impossibilityof the performance of any working activity; this is an essen-tially theoretical concept, except when of transitory nature.26,27

Invaliditymay be defined as the total, indefinite, and multiprofessional working disability, notsubject to recov-eryorvocationalrehabilitation,correspondingtoageneral inabilityoffinancialgainasaresultofillnessoraccident.26

CausalandconcausalnexusinWRVD

Accordingtosocialsecuritylegislation,foranaccidenttobe characterizedasawork-relatedaccident,thecausalnexus betweentheworkandtheresultingevent(injuryor disor-der)shouldbeestablished.27

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if,betweenthem,arelationshipofcauseandeffectisnot established.14

Therearesomefactorsthatexcludetheof responsibil-ityofthecausalconnectionofaccidentsatwork:exclusive guilt of the victim; unforeseeable circumstances or force majeure(when the accidentoccurs due tocircumstances or conditions that arebeyond any control or diligenceof theemployer);andthirdpartyfactor (nodirect participa-tionoftheemployerorofthelaboractivityexerciseforthe occurrenceoftheevent).29

Theevidenceinmedicalinspectionsshouldnotbe eval-uatedmechanicallywiththerigorandthecold-heartedness of a precision instrument, but with the rationality of an attentivejudgewhowillcombinefacts,evidence, assump-tions, andthe observation of whatordinarily happens, to formhis/heropinion.29 _Because_of _this,_when_it _comes_to WRVD,andexcludingthesocialsecuritycontext,the medi-calexpert shouldbe an otolaryngologist, considering that thisprofessionalisthebestpreparedtoassessthissituation. Themedicalexpertshouldfollowasystematicstandardized procedure,sothatnorelevantaspectisoverlooked:What doestheworkerdo?Howdoeshe/sheperformhis/herjob? Withwhatproductsandtools?Where?Underwhich condi-tions? Howlong? How he/shefeels andwhat does he/she thinksaboutthejob?Doeshe/sheknowotherworkerswith similarproblems?Whatwashis/herformeroccupation?14

Importantly,fortheinvestigationofhealth/work/disease relationships,itisessentialtoconsidertheworker’sreport, both individually and collectively. Despite the advances and sophistication of techniques for the study of working environmentsandconditions,oftenonlytheworkerknows howtodescribetheactual conditions,circumstances, and unforeseeneventsthatoccurineverydaylifeandthatcould explainhis/herillness.However,inthemedicalexpertwork, it is of paramount importance to seek information from other parties involved in the compensation process, i.e., thecompanyclaimed,forduevalidationoftheinformation obtainedfromthecomplainingparty.14

The Brazilian Federal Boardof Medicine, in the useof itslegalattributions,andconsideringthateveryphysician, whencaringforapatient,andinthiscasethepersonobject oftheinvestigation,mustevaluatethepossibilitythatthe causeoftheallegeddisease,clinicalchange,orlaboratory abnormalitymayberelatedwiththeprofessionalactivity, asissued the Resolution CFM1,488/1998, which statesin itsIIarticle:‘‘Article2---Toestablishacausalrelationship betweenhealthdisordersandtheactivitiesoftheworker, in addition to clinical(physical and mental) examination and supplementary tests, when necessary, the physician should consider:I---the clinicalandoccupational history, decisiveinanydiagnosisand/orinvestigationofcausality; II --- the study of the workplace; III --- the study of work organization; IV --- epidemiological data; V --- the current literature; VI --- the occurrence of a clinical or subclini-calpicture in aworker exposedto aggressive conditions; VII --- the identification of physical, chemical, biological, mechanical,stress,andotherrisks;VIII---thetestimonyand experienceofworkers;IX---theknowledgeandpracticesof other disciplinesand oftheirprofessionals, pertainingor nottothehealtharea.’’30

Theworker’sillnessesthatrelatetohis/herprofessional activitycomprisetheclassificationofoccupationaldiseases,

beingregarded,forsocialsecurityandindemnitypurposes, aswork-relatedaccidents,inaccordancewithArticle20of LawNo.8,213/91.31

Withrespecttooccupationaldiseases,thelegislationhas adoptedtheclassificationofSchilling,consideringwhether thediseaseagentwasprovocativeorcontributory.Theterm ‘‘occupational disease’’ is a generic term that is subdi-videdintoprofessionaldiseasesandworkingdiseases,that areforeseenin article 20, paragraphsI andII of LawNo. 8,213/91.16

Schilling(1984)classifiedtheoccupationaldiseasesinto threegroupsapud:14

GroupI(professionaldiseases,ergopathies,idiopathiesor technopathies): diseases that are produced or triggered only by certain professional activities, e.g., silicosis in miners exposed to silica, lead poisoning (saturnism) in workersexposedtolead.Thetypeofcausalrelationissaid ‘‘necessarycause’’andexemptsproofofcausationnexus withtheworkdue toitstypicality,26 _that_is,_in _such dis-easesthecausation ispresumed inLaw(jurisetdejure

presumption).31

Group II (work diseases, ‘‘atypicalprofessional illnesses ordiseases’’ormesopathies):diseasesinwhichthework maybeariskfactor,butnotnecessarily,i.e.,thework dis-easesdo nothave assoleor exclusive causethe service performed,butareacquiredasaresultofthespecial con-ditionsunderwhichtheworkisperformed.31_There_is_a_kind of causal relationship with a ‘‘contributory’’ risk factor ofmultifactorialetiologythatrequiresproofofcausation nexuswiththeworkperformedunderthesespecial condi-tions,usuallythroughinspectionoftheworkplace.16_WRVD isincludedinthisgroup.

GroupIII(concausalfactor):evenifthejobexecutionhas notbeen thesoleandexclusivecauseoftheaccidentor occupationaldisease,suchcasualtywillbeconsidered as being a work-related accident for the purposes of Law, whentheworkingconditionsdirectlyconcurforthe occur-rence of the misfortune.31 _This _{‘‘concurrent} _cause’’ _is called by doctrine as ‘‘concausal factor’’.31 _Very _often, WRVDisincludedinthisgroup(voicedisorders).Thekind ofcausalrelationshipwiththeworkpresentsapreexisting disease‘‘triggeringoraggravating’’factor.14

As a basic guideline, the positive response to most questionspresented belowhelps toestablish an etiologic relationshiporcausationnexusbetweenillnessandwork:14 Natureof exposure: canthe pathogenbe identifiedby occupationalhistoryand/orbytheinformationcollectedin theworkplaceand/orfrompeoplefamiliarwiththeworker’s environmentorworkplace?

Specificity of the causal relationship and the strength ofcausal association: the pathogenor risk factor maybe contributingsignificantly among the causalfactors of the disease?

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• Degreeorintensityofexposure:isitcompatiblewiththe

productionofthedisease?

• Exposuretime:isitsufficienttoproducethedisease? • Latency period: is it sufficient for the installation and

manifestationofthedisease?

• Previousrecords:arethererecordsconcerningtheformer

worker’s health state? Ifso,dothese contributetothe establishment ofacausalrelationship betweenthe cur-rentstateandthework?

• Epidemiological evidence: is thereepidemiological

evi-dencetosupportthehypothesis ofacausalrelationship betweenthediseaseandthepresentorpreviousworkof theinsuredworker?

The pathologiesrelatedtotheworkingactivity arenot onlythosecaused bya laborfactor, butalsothose aggra-vated by some agent present in the workplace, that is, a concausal factor.Thus, the concausalfactor is another causethat,togetherwiththemaincause,contributestothe result,notbeingresponsibleforinitiatingthecausalprocess neitherforinterruptingit---itisjustareinforcement.29

The principleofconcausality,according towhich there isnoneedthattheworkbethesolecauseofthedisabling event,wasonlyadoptedbyDecree-LawNo.7,036/44.This principleiscurrentlyineffect,beingconsideredinArticle 21, item I of Law 8,213/91: ‘‘The work-related accident that,although not being the onlycause, has contributed directlytothedeathoftheinsuredperson,tothe reduc-tionorlossofhis/herability towork,orproducedinjury requiringmedicalattentionforhis/herrecovery.’’16

Withinthetheoryofconcausality,antecedent, concomi-tantandsubsequentcausesmayexist.16

Anantecedentcausepreexiststhetraumaticevent,but isinstrumentalfortheresulttohappenthatwayandatthat time.Forexample,aninsureddiabeticwhosuffersaminor injurythat,ifit happenedina healthyworker,wouldnot havemajorconsequences.However,theinjurycausedheavy bleedingthatleadtodeath.Thisisapreexistingconcausal factor,becausewithoutittheresulting‘‘death’’wouldnot havehappened.16

Superveningcausesorfactorsoccuraftertheevent.An exampleis acomplicationcaused bypathogenic microbes afteranaccident,withanendresultofamputationofthe affectedfinger.16

Finally,concomitantfactorsarethosethatcoexistwith theaccident.Forexample,ahearinglossthataffectsa50 yearsold worker exposed tonoise in the workplace. The hearinglosscanbecausedbyexposuretohigh environmen-talnoiseduring20or30yearsofwork,butthisdefectmay alsobearesultoftheagefactor.16

Conclusion

WRVDisasituationthatappearsfrequentlyasacausefor work absenteeism or functional rehabilitation, or still for prolongedabsencefromwork.Currently,forensicphysicians havenocomparativeparameterstoconductanexpert anal-ysisinvocaldisorders.Incertainsituations,WRVDmaycause workdisability.Thisdisordermaybelabor-related,orbean adjuvantfactortowork-relateddiseases.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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