20Q: Pediatric Voice Disorders: Diagnostic and Treatment Approaches

In most cases, children are able to tolerate a rigid laryngoscopic examination or a flexible nasoendoscopic laryngeal exam without significant discomfort. Major medical centers that perform these examinations frequently with children often have a preparatory protocol for the child and their family which might include a coloring book/child-focused information book sent prior to an appointment. At a minimum, the procedure will be explained to the child (as appropriate to the child’s age) and topical anesthetics can be used in some cases to increase the tolerance of the exam. 

6. What are some ways to evaluate voice without instrumentation for acoustics and aerodynamics?

It is definitely recognized that most speech-language pathologists in a school setting or sometimes other pediatric settings will not have access to instrumentation for acoustic/aerodynamic measures, but still desire to document baseline function and have a means to track progress over time. While “low tech” options due exist, it is important for clinicians to understand their limitations and critiques of the methods. One of these lower technology measures is maximum phonation time (MPT). MPT is obtained by asking a child to sustain a vowel at a comfortable loudness and pitch level for as long as possible after taking the largest breath possible. The sustained phonation can be measured on any electronic device with a stopwatch (e.g., smartphone). The reliability of this measure is very much tied to the child breathing in to total lung capacity and breathing out to residual volume, which obviously cannot be measured in most environments. As with any maximum performance task, multiple measures (e.g., 3 attempts) should be obtained. Another lower technology measure is s/z ratio in which the child is asked to sustain a /s/ and then a /z/ for as long as possible, similar to the manner described for MPT. Again, multiple trials are essential, but one of the major difficulties with this measure is that the time of the /s/ is compared to the /z/. In general, the literature shows that children who have healthy vocal folds have a 1.0 s/z ratio (Tavares, et al., 2012), however, if the /s/ is much longer than the /z/ this can indicate that there is glottal incompetence due to a lesion or other abnormality of the vocal folds. Tavares and colleagues provide one study in which normative values are given for both MPT and s/z ratio. 

7. What is the most common voice disorder diagnosed in children? 

Vocal fold nodules are by far the most common cause of dysphonia in a child. Vocal fold nodules are bilateral, subepithelial, callus-like lesions that are generally the result of repeated trauma from voice misuse. However, as stated above, children may also have congenital laryngeal disorders which can include vocal fold cysts, laryngeal webs, and vocal fold paralysis. Furthermore, children can develop vocal fold polyps and granulomas similar to adults. Functional disorders, such as puberphonia, are described later in this article. 

8. Can gastroesophageal reflux and eosinophilic esophagitis cause voice problems in children? 

Yes, they can, particularly acid irritation from reflux. Any irritant like gastroesophageal reflux (GER) that breeches the laryngeal airway can inflame laryngeal tissue or exacerbate an existing condition. As part of the history, the pediatric patient and their parent are always asked about symptoms of reflux (throat clearing, lots of burps, stomach aches, difficulty swallowing, etc.). Examination of the laryngeal and hypopharyngeal area tissue are part of any laryngeal examination. Commonly described indirect evidence of acid irritation to the tissue in that area is erythema (redness), edema, and hypertrophy or thickened tissue. Otolaryngologists (OTL) frequently prescribe anti-reflux medications and diet regimens to treat GER.  OTLs may treat a patient for GER, regardless of a formal GER diagnosis, prior to any type of laryngeal/airway surgery to be sure the area is as “quiet” as possible during the peri- and post-operative period. Eosinophilic esophagitis (EE) is an allergic inflammation of the esophagus thought to be an allergic reaction to certain food groups. EE can aggravate symptoms of reflux and add to the child’s discomfort. A tissue biopsy is needed to formally diagnose eosinophilic esophagitis. If diagnosed, EE is treated with medication and diet change (Kelchner, Brehm, & Weinrich, 2012).

9. What are the challenges to seeing a child for a voice disorder in a school setting? 

The primary challenges associated with treating pediatric voice disorders in the school system include the ability of the clinician to provide compelling evidence that the presence of a voice disorder is educationally handicapping for the child; clinician caseload burden and perception that a voice disorder is a lower priority communication disorder; and limited clinician confidence with treating a voice disorder (Hartley, Braden & Thibeault, 2017).

10. How does a voice disorder impact academic performance? 

There are no clear data on exactly how the presence of a voice disorder impacts specific academic abilities unless there is an underlying etiology that is common to both the voice disorder and cognitive abilities that support a particular academic skill set (i.e., math, science, etc.). However, there are published data that show female children with voice disorders, particularly those that are more severe, can be viewed as less healthy, sociable, happy, intelligent, and employable by teachers (Zacharias, Kelchner & Creaghead, 2013). Intelligibility of connected speech is often compromised in children with voice disorders, particularly in the presence of background noise. Children may be asked to repeat themselves more often, not be called on in class, or may withdraw from classroom participation and other activities, such as music and theatre. Parents are often quite concerned about their child’s school experiences and their ability to fully participate in academic and related activities.

11. Is surgery recommended to treat vocal fold nodules or other lesions of the vocal folds? 

Surgery for a vocal fold lesion may be considered under certain circumstances if a course of therapy has been attempted (and the child has been compliant with recommendations) and no improvement is observed. Additionally, there are lesions that cannot be resolved with voice therapy alone including vocal fold cysts, some vocal fold polyps, particularly fibrous vocal fold nodules, and respiratory papillomas. There are many factors to consider prior to a recommendation for vocal fold surgery for a child. The child must demonstrate an ability to follow post-operative recommendations in terms of limited voice use, as well as any recommended follow-up therapy. It is preferable to have an otolaryngologist with specialized training in pediatrics and microflap techniques for optimal outcomes.   

12.  Will nodules just go away over time, as a child gets older?

Each child with vocal fold nodules will have varying precipitating factors and varying biological and environmental factors that will influence the evolution of the vocal nodules over time. Past studies have attempted to address this issue and in one such study it was found that in 21% of the study population (children with vocal fold nodules), voice complaints, including hoarseness, persisted post-puberty (deBodt et al., 2007). There are times when a “wait and see” approach may be appropriate if the child is too young or not cognitively able to participate in behavioral therapy or if the family feels they cannot attend or be compliant with voice therapy at the current time. In general, for those lesions that are amenable to voice therapy, it is generally thought that voice therapy should be attempted in children. 

13. So does voice therapy work in children? Are there any evidence-based therapy programs for children?

There is a growing body of literature that documents positive outcomes for children, primarily with vocal fold nodules, who have undergone behavioral voice therapy. Several studies have demonstrated improvements in acoustic measures and voice quality measures in children with vocal fold lesions after a course of voice therapy (e.g.,    Senkal & Ciyiltepe, 2013; Tezcaner et al., 2009; Trani et al., 2007; Valadez et al., 2012). One of the most recent contributions to the evidence-base for voice therapy in children was a randomized clinical trial by Hartnick and colleagues (2018) which examined the impact of voice therapy treatment methods in 114 children with vocal fold nodules ages 6 to 10 years old. Two therapy methods were examined. One focused more on direct therapy techniques for modifying the voice and the other was more of an indirect program that focused on modifying voice use and the child’s environment. Both techniques demonstrated positive outcomes which did not differ significantly on a voice quality of life scale. 

14. What is the youngest age that a child can participate in voice therapy?

Children typically speak their first words by 12 months, but they vocalize when they produce their first cry. If the pediatrician, pediatric nurse, and/or parents are concerned about the child’s vocal quality (breathiness, roughness, strain, pitch, loudness), a speech-language pathologist and pediatric otolaryngologist should be consulted. With children who are pre-toddlers, indirect treatment procedures can be performed by instructing the parents. Both indirect and modified, direct treatment approaches can be used with toddlers.

15.  What are some ways to modify voice therapy for children? 

All therapy modifications are personalized for the individual needs of the child with a voice disorder. The indirect treatments to eradicate vocal trauma must specifically address the voicing behaviors, and those behaviors beyond voicing, that exacerbate vocal abuse. For hygienic voice therapy to be effective, the clinician must obtain a thorough intake history that identifies all the abusive behaviors (e.g., vocal use, phonotrauma, hydration, gastroesophageal or laryngopharyngeal reflux) and are pertinent to the child with a voice disorder. The child, parent, and educators must all be active participants in modifying these behaviors, including using charts and reward systems that are meaningful to the child. Direct treatment approaches can be modified for young child by using visual imagery, such as, “gliding upward or downward with a toy airplane” for vocal glides or using technology with apps and/or gaming options for various voice parameters. Additionally, meaningful verbal representations, such as “buzz like a bee” for lip buzzes can enhance task performance. Rather than matching notes for vocal exercises, young children can produce comfortable low, middle, and high-pitched notes. Sentence and phrase lengths can be shortened for resonance therapy. Blowing bubbles and straw phonation are useful for semi-occlusion of the vocal tract. It is important to consider the personality of the child and combine vocal exercises with kinesthetic movement in creative manners that engage the child and increase compliance.

16. What are some aspects of voice that an SLP could evaluate in a child who is a singer with a voice disorder?

An SLP’s voice assessment of child who is a singer would not vary notably from a child who is a non-singer. A comprehensive voice history is imperative and should highlight¬¬ voice use, aberrant vocal symptoms, type/amount of singing, medications, allergies, and extensive vocal hygiene information. The assessment protocol should examine perceptual, acoustic, and aerodynamic features of voice, as well as the endoscopic/stroboscopic characteristics of the laryngeal system to assess glottic closure patterns, supraglottic activity, vocal fold edge, mucosal flexibility, laryngeal movement patterns, etc. An SLP with training in vocal performance could provide a technical voice assessment to evaluate voice breaks during vocal slides and within a singing passage, as well as use of registers, overall breathiness, overall timbre, and voice/vocal quality in the singing passage. Any dysphonia, loss of frequency range, throat pain, resonance abnormalities, or abnormal vocal/physiologic findings in the formal assessment should warrant referral to an otolaryngologist to evaluate possible laryngeal pathology.

17. Is it beneficial for a child to take private voice lessons?

Children with an aptitude and enthusiasm for singing may benefit from private or group lessons. Professional children’s choirs can be found in larger populated regions. These can enhance good vocal techniques. Some community theater productions are designed for child performers. Private voice instructors should provide vocal training that enhances flexible laryngeal musculature to train neuromuscular patterns using repetitive vocal drills. These drills promote agility and flexibility; therefore, they should be enticing to the children so that they perform them in daily practice. Whether it is a private lesson, group lesson, or vocal studio, the objective should be to promote a healthy, efficient singing voice and prevent vocal injury.

18. I have a high school athlete on my caseload with paradoxical vocal fold dysfunction (PVFD) – what do I do?

PVFD occurs when the vocal folds involuntarily adduct during the inspiratory phase of breathing and create an obstruction in the airway. It is typically seen in individuals ages 10 to 40 years, and is related to physical exercise, laryngeal hyperreactivity, or emotions. Common characteristics include neck or upper chest tightness and inspiratory stridor. Breathlessness, coughing, and voice change may be observed. It is important to identify the triggers for episodes, and these events should be journaled for stressors, foods, and environmental conditions. When the behaviors are identified, strategies, such as progressive relaxation techniques, should be developed to improve function. Respiratory training techniques should include abdominal breathing, panting, and pursed-lip inhalation. Finally, the high school athlete needs to gain independence through self-awareness to use the learned techniques when a stimulus arises.

19. What is puberphonia and how do I treat it?

Puberphonia is a functional voice disorder that is characterized by a high-pitched voice, more commonly seen in males following puberty. Also, the voice may be breathy with a soft volume. There may be a psychological cause (e.g., emotional/social immaturity or gender identification issues) and/or a medical cause. Therefore, a medical evaluation should be performed to identify whether the cause is hearing loss, delayed maturation of laryngeal structures due to endocrine disorder, or neuromuscular control issues. Treatment techniques could include laryngeal massage therapy, reduction of tension during speech, and visual biofeedback with speech software to mark acceptable frequency ranges during speech. When the lower-pitched voice is accomplished in unstructured speech tasks, the use of the appropriate voice with family members and peers may require support from the clinician. 

20. I have a child on my caseload who had airway reconstruction at age 2 years. The child now vocalizes with his false vocal folds. Why does he do that? How can I help him? 

There are a number of reasons that a child who has undergone airway reconstruction might utilize the false vocal folds for phonation. Following airway surgery, there may be laryngeal nerve damage that causes paresis or paralysis to one or both true vocal folds. Children are highly skilled at utilizing other laryngeal structures to establish a vibratory source. Often the goal of voice therapy for children who must use supraglottic structures to phonate is to help them find the best sounding voice that is also the most efficient (high subglottal pressures to initiate phonation with these structures are often needed). Semi-occluded or modified resonant voice exercises may assist in finding these voicing patterns and extending them into connected speech. In some cases, depending on the voice demands for the child, amplification devices may be appropriate in some classroom situations (e.g., presentations). A team-based approach that involves the child, family, hospital-based otolaryngologist/SLP, and the SLP treating in the community will generally provide the best outcomes. More information can be found on evaluation and intervention recommendations for this special population in the text Pediatric Voice: A Modern, Collaborative Approach (Kelchner, Brehm, & Weinrich, 2014). 

References

De Bodt, M.S., Ketelslagers, K., Peeters, T., Wuyts, F.L., Mertens, F., Pattyn, J., et al. (2007). Evolution of vocal fold nodules from childhood to adolescence. Journal of Voice, 21(2), 151-156.

Hartley, N.A., Braden, M., & Thibeault, S.L. (2017). Practice patterns of speech-language pathologists in pediatric vocal health. American Journal of Speech-Language Pathology, 26, 281-300.

Hartnick, C., Ballif, C., De Guzman, V., Sataloff, R., Campisi, P., Kerschner, J., et al. (2018). Indirect vs direct voice therapy for children with vocal nodules: A randomized clinical trial. JAMA Otolaryngology-Head & Neck Surgery. 144(2): 156-163.

Kelchner, L., Baker Brehm, S., & Weinrich, B. (2014). Pediatric Voice: A Modern, Collaborative Approach to Care. Plural Publishing, San Diego, CA.

Senkal, A. & Ciyiltepe, M. (2013). Effects of voice therapy in school-age children. Journal of Voice, 27(6), 787.e19-e25.

Tavares, E.L.M., Brasolotto, A.G., Rodrigues, S.A., Benito Pessin, A.B., & Garcia Martins, R.H. (2012). Maximum phonation time and s/z ratio in a large child cohort. Journal of Voice, 26, 675.e1-675.e4.

Tezcaner, C. Z., Karatayli Ozgursoy, S., Sati, I., & Dursun, G. (2009). Changes after voice therapy in objective and subjective voice measurements of pediatric patients with vocal nodules. European Archives of Oto-Rhino-Laryngology, 266(12), 1923-1927.

Trani, M., Ghidini, A., Bergamini, G., & Presutti, L. (2007). Voice therapy in pediatric functional dysphonia: a prospective study. International Journal of Pediatric Otorhinolaryngology, 71(3), 379-384.

Valadez, V., Ysunza, A., Ocharan-Hernandez, E., Garrido-Bustamante, N., Sanchez-Valerio, A, & Pamplona, M. (2012). Voice parameter and videonasolaryngoscopy in children with vocal nodules: A longitudinal study, before, and after therapy. International Journal of Pediatric Otorhinolaryngology, 76, 1361-1365

Zacharias, S. Kelchner, L., & Creaghead, N. (2013). Teachers’ perceptions of adolescent females with voice disorders. Journal of Speech-Language Hearing Services in Schools, 44, 174-182.