**7. Summary and perspectives**

During the last two decades, Health Sciences research has evolved from a purely biological perspective towards a biopsychosocial model of health and disease. As a result, it has been found that there is a relationship between voice disorders and neuro-vegetative responses associated with emotional responses, mainly those related to anxiety and stress. These responses are generated by the activation of the hypothalamic defense areas and are carried by the PAG and pontomedullary structures such as the PBc and A5. The emotional response intervenes, along with other psychological factors, on the tone of the laryngeal muscles causing spasmodic dysphonia or laryngeal dysphonia. This occurs because the laryngeal muscles appear to be extremely sensitive to emotional stress generated by anxiety, anger, irritability, impatience, frustration, and depression, which can lead to spasmodic dysphonia or laryngeal dystonia [69]. Along these lines, Demmink-Geertman et al. [72] confirmed that, due to the characteristics of the higher pitch of the female voice, this effect is greater in women of all ages and that, above all, it affects professionals who use the voice as a means of work. This fundamentally affects women involved in teaching tasks. Only in Andalusia, the number of teachers is 132,985, and in Spain, they exceed 750,000, of which 71.9% are women. The percentage is particularly relevant in early childhood (97.6%), special (81.7%) and primary (81.4%) education. At least 21% have vocal involvement and 15.8% of sick leave is due to voice problems (FETE-UGT 2019 teaching report). Knowing the pathophysiology of the mechanisms by which stress produces alterations in the functionality of the vocal cords would allow the development of adequate treatments for these pathological processes.

Therefore, new contributions are needed to add new perspectives to a series of pathologies that are related to mechanisms that have their origin in these hypothalamic-midbrain regions, such as the so-called central apneas associated with hypertension [70], apneas associated with sudden death infantile syndrome [73], paradoxical laryngeal adduction movements [71] and muscular tension dysphonia secondary to stress [74].
