Steps You Should Take to Protect Your Voice and Hearing During Telemedicine Sessions

Our lives have changed significantly since COVID-19’s onset. Among those changes is a broad shift toward working from home and socializing virtually. For many of us, that means extended hours using video-enabled virtual communication systems. Professionally, these platforms have allowed us to provide services to our patients remotely. While there are clear benefits to virtual communication, extended use can also increase the risk of developing voice and hearing problems.

If telehealth is part of your new normal, you may need to make changes to maintain a healthy work environment and preserve your auditory and vocal health. Your physical office might have everything you need for meetings: a quiet space, a desk or table, and comfortable chairs. Your virtual office needs to include appropriate communication technology to reduce the risk of voice and hearing problems.

Vocal Health

“Cell yell” describes a person’s tendency to talk more loudly than usual when using a cell phone or speaker phone (Taub EA. Cell yell: Thanks for (not) sharing. New York Times. November 22, 2001:G1). The term predates the advent of videoconferencing, but recent research shows we have the same tendency to increase vocal loudness when using video calls (Perspect ASHA Spec Interest Groups. 2019;4:538–541).

The phenomenon of increased vocal loudness in heavy background noise (the Lombard effect) in conjunction with altered auditory feedback and the perception of distance exacerbate cell yell. The Lombard effect was previously understood as a subconscious increase in vocal loudness when background noise rises. We now know it’s a complex and dynamic modification of voice production in response to real-time changes in the perception of one’s own voice (Curr Biol. 2011;21:R614–R615). Virtual communication alters perception, and, as a result, we inadvertently increase vocal loudness, thereby increasing vocal dose.

Vocal dose quantifies exposure of vocal fold tissue to vibration and is dependent on vocal intensity, fundamental frequency, phonation time, and individual variation in vocal efficiency. In a systematic review, authors found that talking more loudly than usual for an extended time is associated with a higher risk of injury to the vocal folds, vocal fatigue, and voice changes perceived as hoarseness (Rev CEFAC. 2017;19:429-438).

As clinicians, we’re aware of the risks of cell yell and increased vocal dose, but we might not be practicing what we preach to avoid it. While we would typically use natural breaks during a day of seeing patients in person to stay hydrated and rest, we may now be experiencing an increase in vocal effort and fatigue. Our experience has been that patients and providers alike are noticing voice problems related to more frequent and longer virtual communications. Individuals report vocal fatigue and strain, tension or lump-in-the-throat feeling, and voice changes associated with spending long hours speaking.

To prevent voice symptoms, proactively take steps to optimize vocal health and wellness. We’ve developed these recommendations to maintain your vocal health throughout a series of telehealth sessions:

• First, reduce your vocal dose by incorporating short periods of complete silence, or vocal naps, throughout the day—about 15 minutes should suffice.
• Second, stay well hydrated. Research suggests that dehydration can negatively affect the sound and feel of your voice due to changes in the biomechanical properties of the vocal folds, causing them to vibrate less efficiently (J Voice. 2019;33:125.e13-125.e28; J Voice. 2010;24:637-643).
• Third, warm up with gentle humming or lip trills to prepare your voice for a day of increased vocal demands.
• Finally, pay attention to how loudly you speak during virtual communications. Improve your setup with technology that allows you to more accurately perceive your own loudness.

Auditory Health

Our auditory system is also at risk when we engage in telemedicine. Long-term headphone use at hazardous levels is associated with hearing loss derived from the intensity of the auditory signal and the period of time your auditory system is exposed (Ann Otol Rhinol Laryngol. 2018;127:703-709; J UOEH. 1986;8 Suppl:151-161). Distance also plays a role, as Robert Hooke’s inverse square law indicates that doubling the distance from a sound source will reduce sound pressure level by 6 decibels. It’s important to monitor the output levels given the proximity of the sound source to the ear while wearing headphones. Even when exposed to moderate sounds over an extended time period, individuals can experience temporary threshold shifts, tinnitus, and sensorineural hearing loss (Noise Health. 2012;14:274-280).

The goal should be to send the cleanest signal possible so that our patients can take away the maximum amount of information during appointments.

Technology Considerations

The quality of the tools we use impacts how well we can communicate. Consider the communication tools that come standard with your laptop: A thin, pinhole microphone placed next to a camera and miniature speakers designed to fit in a compartment next to the thousands of components that enable the computer to operate. While these tools are fine for intermittent communication, they may not be helpful for long-term use.

Speakers/Earphones. Laptop speaker portability comes with restrictions. Internal speakers are often placed too close to the screen, resulting in reverberating sound waves. These waves can cause unwanted effects, increasing distortion and decreasing clarity. Furthermore, the speaker’s miniature scale prevents a full sound, with low frequencies underperforming. To correct for this, we tend to max out the volume to overcome environmental noise, resulting in scratchy or distorted output.

Headphones can help mitigate unwanted echoes and send a signal straight to your ears, but not all headphones are created equal. Earbuds, for example, fit more loosely compared to better-encased insert headphones or over-the-head headphones, and young adults using earbuds tend to listen to them at a louder volume compared to other headphone types (J Am Acad Audiol. 2017;28:295-313). Open access allows for more competing noise, and that prompts listeners to increase the audio source volume.

Circumaural headphones encompass the ear and are preferable for videoconferencing due to the richer frequency response offered. They also prevent the need to increase the volume beyond a reasonable level.

Microphones. Many clarity issues stem from inadequate microphone capability. A laptop’s small microphone is sensitive to environmental noise, which can mask important speech information. It’s also stationary and not sensitive to changing head positions during an appointment.

As clinicians, we’re aware of the risks of cell yell and increased vocal dose, but we might not be practicing what we preach to avoid it.

Dynamic USB microphones are robust, can be plugged directly into a USB port, and may be more directional. Built-in headsets move with you and are less bulky. An audio interface, on the other hand, while stationary and cumbersome, is a complex sound hub that allows for customization, as it heightens the ability to meticulously control audio signals to and from your computer, with independent control of input and output.

Environment Optimization. Be sure to choose a brightly lit room where your face can be clearly seen without interfering shadows. We rely on visual cues when communicating, and the ability of patients with hearing loss to see our mouths strongly improves their ability to understand us (PloS One. 2009;4:e4638).

Mitigating distracting sounds can also keep you from increasing volume louder than needed. Fans, hums, or buzzes impose a challenge on both you and your patients. Choose a quiet room in which to conduct appointments to avoid unwanted distraction for both parties.

Also consider smaller rooms that have soft, permeable furnishings to better absorb sound. Rooms with many reflective surfaces and high ceilings add reverberation that can make listening difficult. When these factors are paired with a poor, distant microphone on your end, patients receive a signal tainted with undesirable artifacts.

Telehealth, while different than in-person appointments in many ways, can exceed expectations with tools that allow patients greater access to information. The goal should be to send the cleanest signal possible so that our patients can take away the maximum amount of information during appointments.

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John Parsons, Alaina Bassett, and Rebecca Lewis are audiologists with the Keck School of Medicine at USC; M. Eugenia Castro and Lauren Timmons Sund are speech-language pathologists with the Keck School of Medicine at USC.