倾听声音背后的声音：为嗓音密集型职业开发职业特异性患者报告结局测量工具

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中文摘要

引言： 嗓音对于嗓音密集型职业中的身份认同和生计至关重要。嗓音要求高的职业涵盖四大类别：表演性嗓音使用者（歌手、演员）；教学性嗓音使用者（教师）；沟通密集型专业人员（播音员、政治家、律师、电信办公室工作人员）；以及神职人员或仪式性嗓音使用者。即使是轻微的发音困难也可能扰乱表演和职业稳定性。尽管喉镜检查和嗓音外科手术的进步改善了结构性结局，但在耳鼻喉科实践中，当前的结果评估仍主要锚定于解剖学和声学恢复，而根据我们的临床经验，职业特异性功能较少被一致地捕捉。现有的嗓音相关患者报告结局测量工具（PROMs），如嗓音障碍指数（VHI及其简表VHI-10）或歌唱嗓音障碍指数（SVHI和SVHI-10），可能无法完全捕捉不同职业嗓音使用者所特有的职业特异性关切、嗓音需求和恢复期望。
目的： 探讨并比较八个职业嗓音使用者群体的职业特异性关切、嗓音优先事项、功能需求和恢复阈值，并设计一种新的职业特异性嗓音PROM（PS-PROM），以反映职业特异性的关切和考量，并可作为VHI/VHI-10和SVHI/SVHI-10的补充工具整合到耳鼻喉科嗓音诊疗中。
方法： 开展了一项定性访谈研究，采用半结构化访谈，纳入来自八个职业的40名参与者（每个职业n=5），分为四个职业类别：表演性嗓音使用者（歌手和演员）；教学性嗓音使用者（教师）；沟通密集型专业人员——分为广播和高曝光沟通（媒体播音员、政治家）以及持续沟通耐力（律师、电信办公室工作人员）；以及神职人员/仪式性嗓音使用者。访谈进行录音，逐字转录，并使用Braun和Clarke的六步框架进行主题分析。候选PROM条目采用0-10数字评定量表（NRS）格式从访谈数据中归纳得出。拟议工具包括用于门诊的简短筛查版本和用于研究和专科诊所的扩展版本。该工具尚未经过心理测量学验证；这是计划的下一阶段。
结果： 四个类别中出现了不同的嗓音关切和需求。表演性嗓音使用者（歌手、演员）优先考虑音色细腻度和表现力。教学性嗓音使用者（教师）强调嗓音耐力和日终疲劳。在沟通密集型专业人员中，播音员和政治家重视清晰度、感知到的嗓音可靠性以及在高曝光环境中的快速恢复，而律师和电信办公室工作人员则共享一种持续、高数量日常沟通的共同功能特征，尽管需求的性质不同：律师在无扩音的法庭陈述中需要嗓音投射，而电信办公室工作人员通过头戴式麦克风以正常对话强度说话，其主要负担来自通话频率、轮班时长以及对休息和节奏的有限自主权，而非嗓音响度。神职人员识别出持续仪式性和 devotional 嗓音使用的独特维度。在所有群体中，发音困难被视为对身份认同、生计和信心的重大威胁，情绪困扰始终超过身体症状。这些维度未被现有PROMs专门评估。
结论： 这是首个提出候选职业特异性嗓音PROM的定性访谈研究，该工具基于来自四个中性类别的八个嗓音要求高的职业的叙述。PS-PROM旨在补充现有PROMs（VHI/VHI-10、SVHI/SVHI-10），通过捕捉职业特异性的功能结局，这些结局可能未被喉部检查结果或一般嗓音障碍评分完全反映。正式的心理测量学验证，包括信度、结构效度、反应性和最小临床重要差异（MCID）的确定，将在计划的后续研究中进行。

英文摘要

INTRODUCTION: Voice is central to identity and livelihood in vocally intensive professions. Vocally demanding occupations span four broad categories: performing voice users (singers, actors); instructional voice users (teachers); communication-intensive professionals (broadcasters, politicians, lawyers, telecommunication office workers); and clergy or ritual voice users. Even minor dysphonia can disrupt performance and professional stability. While advances in laryngoscopy and phonosurgery have refined structural outcomes, current outcome assessment in ENT practice remains anchored predominantly to anatomical and acoustic recovery, with profession-specific functionality, in our clinical experience, less consistently captured. Existing voice-related patient-reported outcome measures (PROMs), such as the Voice Handicap Index (VHI and its short form, VHI-10) or Singing Voice Handicap Index (SVHI and SVHI-10), may not fully capture the profession-specific concerns, vocal demands, and recovery expectations unique to diverse professional voice users.
OBJECTIVE: To explore and compare the profession-specific concerns, vocal priorities, functional demands, and recovery thresholds of eight professional voice user groups and to design a new Profession-Specific Voice PROM (PS-PROM) that reflects occupation-specific concerns and considerations and can be integrated into ENT voice care as a complementary tool alongside the VHI/VHI-10 and SVHI/SVHI-10.
METHODS: A qualitative interview study was conducted using semi-structured interviews with 40 participants drawn from eight professions (n=5 per profession), grouped into four occupational categories: performing voice users (singers and actors); instructional voice users (teachers); communication-intensive professionals - grouped into broadcast and high-visibility communication (media broadcasters, politicians) and sustained-communication endurance (lawyers, telecommunication office workers); and clergy/ritual voice users. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically using Braun and Clarke's six-step framework. Candidate PROM items were derived inductively from the interview data using a 0-10 Numerical Rating Scale (NRS) format. The proposed instrument comprises a short screening version for outpatient use and an expanded version for research and specialty clinics. The instrument has not yet undergone psychometric validation; this is the planned next phase.
RESULTS: Distinct vocal concerns and demands emerged across the four categories. Performing voice users (singers, actors) prioritized tonal finesse and expression. Instructional voice users (teachers) emphasized vocal stamina and end-of-day fatigue. Within communication-intensive professionals, broadcasters and politicians valued clarity, perceived vocal reliability, and rapid recovery in high-visibility settings, while lawyers and telecommunication office workers shared a common functional profile of sustained, high-quantity daily communication, though the nature of the demand differed: lawyers required vocal projection during unamplified courtroom delivery, whereas telecommunication office workers spoke at normal conversational intensity through a headset microphone, with the principal burden arising from call frequency, shift duration, and limited autonomy over rest and pacing rather than vocal loudness. Clergy identified a distinct dimension of sustained ritual and devotional voice use. Across all groups, dysphonia was perceived as a substantial threat to identity, livelihood, and confidence, with emotional distress consistently exceeding physical symptoms. These dimensions are not specifically assessed by existing PROMs.
CONCLUSION: This is the first qualitative interview study to propose a candidate Profession-Specific Voice PROM grounded in narratives from eight vocally demanding occupations across four neutral categories. The PS-PROM is designed to complement existing PROMs (VHI/VHI-10, SVHI/SVHI-10) by capturing profession-specific functional outcomes that may not be fully reflected by laryngeal examination findings or general voice handicap scores. Formal psychometric validation, including reliability, construct validity, responsiveness, and minimal clinically important difference (MCID) determination, will be conducted in a planned subsequent study.