Gaps and Future Directions in the Research About Masking and Voice Production: Bibliometric Analysis, Systematic Literature Review, and Meta-analysis.
Lady Catherine Cantor-Cutiva, Maria Del Pilar Ramirez Ardila, Eric J Hunter
A facemask does not measurably alter the qualities of a person's voice on standard tests, but users consistently report more effort, throat fatigue, and communication difficulty.
The one pooled measure (loudness) did not differ across eight studies.
Key findings
1The pooled loudness result across eight studies showed a mean difference of 0.14 dB (95% CI −0.71 to 0.98), reported as not statistically significant (P = 0.75), with no heterogeneity (I² = 1%).
2Standard voice measures (fundamental frequency, jitter, shimmer, harmonicity, maximum phonation time) showed no significant differences with mask use, while loudness results were contradictory across studies. Cross-sectional studies consistently found mask wearing associated with self-reported vocal fatigue, strain, and increased effort. Simulation studies showed consistent frequency-specific attenuation above 1–2 kHz.
356% of the 48 included publications (27 of 48) were rated weak quality, 25% moderate, and 19% high.
Still to come
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What it does not show
56% of the 48 included publications were rated weak quality, which the authors note limits confidence in the pooled estimates and individual findings. The meta-analysis covered only one outcome (sound pressure level) from 8 studies, so no pooled estimate exists for any other voice parameter. Most studies were conducted in laboratory or controlled settings rather than real-world communication contexts, and few included listener-based tasks or interactive communication. Measurement protocols, mask types, and population characteristics varied considerably across studies, preventing detailed subgroup analyses. The predominance of cross-sectional and repeated-measures designs means the studies cannot establish whether mask use causes the reported vocal fatigue and effort, or whether these symptoms pre-existed. 86% of publications came from 2021–2023, so the evidence base is very recent and still developing.
Declared interests
The authors declare no known competing financial interests or personal relationships that could have influenced the work.
The easy way to misread this
Do not read the null loudness result as evidence that masks are harmless to the voice. The subjective reports of increased effort and fatigue are consistent across the included studies, and the paper argues these represent a real functional load even when acoustic parameters do not change. Conversely, do not read those subjective reports as proof of causation: most included studies were cross-sectional or repeated-measures, and 56% were rated weak quality, so neither the null nor the subjective findings establish that masks cause voice problems.
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