20Q: Pediatric Voice Disorders – A Comprehensive Update on Diagnosis and Treatment

From the Desk of Ann Kummer

Voice disorders are characterized by a noticeable deviance in the quality, pitch, and/or loudness of the voice during speaking. Voice disorders can affect the individual’s ability to communicate clearly, and can also affect the individual’s social and emotional well-being.

Voice disorders in children differ significantly from voice disorders in adults. This is because of the inherent differences between these populations related to anatomy, etiology, and social and emotional influences.

In 2019, Drs. Susan Brehm, Barbara Weinrich, and Lisa Kelchner submitted a 20Q article in which they discussed the causes and characteristics of pediatric voice disorders and provided important information regarding the evaluation and treatment of these disorders. In this article, Drs. Brehm, Weinrich, and Kelchner provide a us with a comprehensive update to their previous article.

Here is information about these esteemed authors:

Susan Baker Brehm, Ph.D., is an Associate Dean in the College of Arts and Science and Professor in the Department of Speech Pathology and Audiology at Miami University. She is also a Research Affiliate at the Center of Pediatric Voice Disorders at Cincinnati Children’s Hospital Medical Center. Dr Brehm joined the faculty at Miami University in 2003 where she taught coursework in anatomy and physiology, research methods, voice disorders, and speech and hearing science. In her role as an associate dean, she supports social sciences programs and multiple areas of health professional education including programs in public health, clinical psychology, gerontology, and a physician associates program. Her research focuses on clinical assessment and voice outcomes in children with laryngeal and other upper airway disorders and she has previously received funding to examine respiratory training in children with upper airway obstruction.

Barbara (Derickson) Weinrich, PhD, is Professor Emerita in the Department of Speech Pathology & Audiology (Miami University - Ohio), Research Associate at the Center for Pediatric Voice Disorders (Cincinnati Children’s Hospital Medical Center), and Fellow of the American Speech-Language-Hearing Association. Dr. Weinrich began her clinical career in 1968 and maintained an active private practice through 2022. She initiated her 39-year career in academia in 1975, teaching courses and providing clinical training in a variety of communication disorders, with a focus on voice and child language disorders. For over 20 years, her clinical research has focused on the assessment and treatment of voice disorders in children and adults, including a variety of approaches to unique voice problems and treatment efficacy.

Lisa Nelson Kelchner, PhD, BCS-S is Professor Emerita in the Department of Communication Sciences and Disorders at the University of Cincinnati, a Research Associate at the Center for Pediatric Voice Disorders (Cincinnati Children’s Hospital Medical Center), and a Fellow of the American Speech-Language-Hearing Association. Dr. Kelchner joined the faculty at UC 2001 where she taught courses in Dysphagia, Voice Disorders, and Neuro Bases of Communication Disorders, among other topics. She served as Interim Chair of the Department of Communication Sciences and Disorders for almost three years and was Director of Graduate Studies for four years. She continues to be involved in clinical research that focuses on the assessment and treatment of voice disorders in children and adults with co-occurring swallowing disorders and topics in telehealth. Dr. Kelchner’s partnership with colleagues at Cincinnati Children’s Hospital Medical Center over 20 years resulted in successful grant funding and development of innovative treatment approaches for children with complex voice disorders.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Pediatric Voice Disorders – A Comprehensive Update on Diagnosis and Treatment

Learning Outcomes

After this course, readers will be able to: 

• Identify the multiple causes of voice disorders in children.
• Describe the diagnostic considerations for evaluating a voice disorder in a child.
• Identify the literature that supports the effectiveness of behavioral treatment of voice disorders in children.

1. Why is it important to talk about pediatric voice disorders as distinguished from adult voice disorders?

There are several important reasons to talk about pediatric voice disorders and how they differ from adult voice disorders, including but not limited to: (a) differences related to anatomy, (b) etiologic correlates, (c) development and learning, (d) social awareness, and (e) family considerations. For example, while the vocal and upper airway anatomy of the infant and child have all the same parts as an adult, the size and proximity of structures to each other and even their tissue make-up (e.g., vocal fold layers and cartilages) differ. The larynx of the infant and child is much higher in the neck, and the laryngeal cartilages (e.g., arytenoids) are softer. With the growth of the child, the relationship of head and neck structures more closely resemble that of an adult by about age seven years. However, the larynx and vocal tract continue to grow and change throughout childhood with dramatic changes occurring during puberty, particularly for males. The layers of the vocal folds for both males and females are not fully differentiated until the early teens. Innervation of the larynx is, of course, the same as an adult (Cranial Nerve 10 and its branches), but the central controls for voice, that allow discreet vocal motor control to support speech, develop over time during the first few years.

Broadly the etiologies of pediatric voice disorders parallel those found in the adult population. There are voice disorders that can be organic in type due to structural, congenital, neurological, systemic, inflammatory, infectious, and traumatic (including iatrogenic) circumstances. Also, there are voice disorders that occur secondary to an inorganic type, such as the range of functional disorders (e.g., overuse, muscle tension dysphonia). When working with the pediatric population it is also necessary to have knowledge of how the various congenital and complex airway disorders can have a unique and life-long impact on a child’s voice. Regardless of the underlying etiology, it is often the case that the presentation, duration, and treatment approaches to pediatric voice disorders vary significantly from those in adults (Kelchner, Brehm, & Weinrich, 2014; Rickert & O’Cathain, 2022).

2. Why must the child be evaluated by a physician, preferably an otolaryngologist, prior to treatment of a voice disorder?

The underlying etiology of a voice disorder must be identified prior to the start of any treatment for any individual at any age. The vocal folds and larynx must be inspected to determine the presence of lesions or other structural and physiological abnormalities. The nature and degree of dysphonia, or simply listening, will not provide the clinician with that information. In children, while bilateral lesions (i.e., nodules) are common, it is also not uncommon for a child to present with a cyst and contralateral edema, recurrent respiratory papillomatosis or unilateral vocal fold paralysis. Each of these requires different treatment approaches. Optimally, the larynx needs to be visualized via a laryngeal mirror, flexible nasal endoscope, transoral rigid endoscope, or even a direct laryngoscopy performed in the operating room.

3. Who are potential members of an interdisciplinary evaluation and treatment team?

An interdisciplinary evaluation and treatment team consists of multiple professionals from varied disciplines. These professionals complement one another to provide a comprehensive evaluation and management plan of care. The specific members of this pediatric team will be determined by the patient’s intake history. Potential members of the interdisciplinary team are speech-language pathologists, general medical practitioners (pediatricians), gastroenterologists, surgeons (pediatric otolaryngologists), medical (and possibly radiation) oncologists, pulmonologists, allergists, nurses, social workers, occupational therapists, dieticians, pharmacists, and caregivers. The speech-language pathologist is the primary treatment provider and may manage the interdisciplinary team treatment following the comprehensive evaluation.

4. What are the standard evaluation tools used to assess pediatric voice disorders?

A comprehensive pediatric voice evaluation needs to reveal the circumstances leading to the development or discovery of the voice disorder; That is, the behavioral, anatomic, physiologic and environmental co-components of the child’s phonatory function and voice use patterns. Typical tasks and questions should examine the circumstances associated with the onset and history of the voice change. Also, how flexible and efficient is the child’s voice? What type of physical effort is needed for voicing? How much does the sound or quality of the child’s voice interfere with their social, academic, and family routines? The answers to these questions and the instrumental measures are the types of data needed for an informed approach to care and documentation of baseline abilities. The evaluation should include a thorough intake (background and history); voice quality of life indices (e.g. Pediatric Voice Handicap Index (pVHI), Pediatric Voice-Related Quality of Life (PVRQoL); standardized clinician perceptual assessment, e.g., the Consensus Auditory Perceptual Assessment of Voice (CAPE-V); acoustic analysis including measures of average fundamental frequency and as possible, frequency range, cepstral peak prominence, and average fundamental intensity; aerodynamic measures, such as average airflow, estimated subglottal pressure, and maximum phonation time; and stroboscopic imaging via use of flexible nasal or transoral endoscopes. Often, the sophisticated instrumentation necessary to obtain some of the aforementioned physiologic parameters related to airflow is not available to clinicians. Reasonable substitutes, carefully calibrated and applied systematically, can be useful for gathering meaningful data. Please see # 6 for more details. (Cohen, Cohen & McGregor, 2015; Heller Murray & Yucel, 2024; Kelchner, Brehm, & Weinrich 2014; Rickert SM & O'Cathain, 2022).

5. Can a child tolerate a laryngeal exam?

In most cases, children can 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 child-focused information book sent prior to an appointment or a website with information about what to expect. 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 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 do 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. 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.

Regarding acoustic assessment, applications for smartphones/tablets are available to conveniently create voice recordings that could be later analyzed using free software, such as Praat. Current research indicates that high quality recordings can be made on smartphones (Awan et al., 2023). There are applications that will also provide some acoustic analyses including fundamental frequency and other measures of interest. It is wise for the clinician to research these applications before using them to determine if there has been any assessment of the validity of the tool.

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 with more occurring in males than females. 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 unilateral or bilateral vocal fold paralysis. Furthermore, children can develop vocal fold polyps and granulomas similar to adults. Functional disorders, such as muscle tension dysphonia, can contribute to the development of vocal fold nodules. Mutational falsetto, or puberphonia, typically occurs during the peripubescent years. Student athletes in particular can present with induced laryngeal obstruction (ILO) (formerly known as paradoxical vocal fold vibration (Adriaansen, Meerschman, Van Lierde, & D'haeseleer, 2022; Hartnick et al., 2018; Kelchner, Brehm, & Weinrich, 2014; Rickert & O’Cathain, 2022).

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 parents 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. GER should be confirmed by formal evaluation by either esophagoscopy and biopsy or ideally by impedance probe testing. 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, 2014; Rickert & O’Cathain, 2022).

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 limiting for the child, clinician caseload burden due to high demand for all communication disorders, and limited availability of speech language pathologists. Moreover, there is the perception that a voice disorder is a lower priority communication disorder, especially when compared to severe communication disorders of childhood including severe speech and language delay and the increasing incidence of children presenting with autism spectrum disorder. There is also documented limited clinician confidence with treating a voice disorder (Hartley, Braden, & Thibeault, 2017). Other barriers to care can exist outside of the school setting including access to a pediatric voice clinician, age, healthcare costs, and proximity to services (Hseu, Spencer, Woodnorth, Kagan, Kawai, & Nuss, 2021). In some instances, the availability of telepractice within the school and healthcare setting can assist in pairing clinicians more familiar with voice disorders and students with voice disorders.

10. Is telepractice an adequate treatment delivery system for pediatric voice therapy?

Use of telepractice (TP) to extend SLP services in the public schools and to use with adults who had difficulty accessing physical healthcare settings was established in the early 2000s. The feasibility of using TP specifically to deliver pediatric voice therapy using synchronous sessions as well as asynchronous web-based practices was tested in 2013. Results of that investigation revealed satisfaction with both approaches, but broad implementation was resisted for financial, technical and professional acceptance reasons. The 2020 Covid-19 pandemic abruptly required many clinicians to offer speech, language, voice and even some swallowing services via TP and as a result, its widespread use continues and has become accepted practice in many settings. Numerous studies have explored the equivalency of in-person versus synchronous internet-based voice treatment delivery and found few differences in effect and user satisfaction. However, using TP still requires thoughtful adaptation of therapy protocols and client/clinician interaction; knowledge of technical issues; and, concerns, privacy, and access to adequate internet access and equipment. When using TP to deliver voice care the clinician must be familiar with the acoustic fidelity concerns, such as signal distortion, that can occur on internet connections particularly during sustained voice samples. In-person pediatric voice assessment is still strongly encouraged and partnering with physicians knowledgeable about pediatric voice is necessary (Doarn, Zacharias, Keck, Tabangin, de Alarcon, & Kelchner, 2018; Kelchner, Fredeking, & Zacharius, 2021).

11. 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., reading, language arts, 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. 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. (Zacharias, Kelchner, & Creaghead, 2013; Rickert & O’Cathain, 2022).

12. 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,e including vocal fold cysts, some vocal fold polyps, particularly fibrous vocal fold nodules, and respiratory papillomas. Some of these lesions have better outcomes with laryngeal microsurgery than others (Martins et al., 2020). 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.

13. 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. Few studies have attempted to comprehensively address this issue but 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). Another more recent study examined adults who had a history of voice disorder and did or did not receive therapy. There were not significant differences in the outcomes of those treated versus not treated with voice therapy during childhood, with most adults reporting no remaining persistent voice disorder at the time of the study. No time regarding length of voice disorder was mentioned (Song, Merchant, & Schloegel, 2017). 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, so intelligibility of connected speech is maximized, and any associated academic, social, and emotional consequences are mitigated (Martins et al., 2020; Rickert & O’Cathain, 2022).

14. 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, perceptual measures, and scales related to quality of life (e.g., Cialente et al., 2022; Senkal & Ciyiltepe, 2013; Tezcaner et al., 2009; Trani et al., 2007; Valadez et al., 2012). Hartnick and colleagues (2018) conducted a randomized clinical trial to examine 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. Andriassen et al. (2022) performed a systematic review looking at the effects of voice therapy in children and found that of the 24 studies included, 8 reported statistically significant improvements, 11 did not show statistical significance but clinical improvement in certain parameters, and five reported no measurable improvement (Cialente et al.; Andriassen et al.). Of note, many of the studies are not directly comparable to each other due to design and methodological factors.

15. 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 an infant, toddler or young child’s vocal quality (e.g., unusual cry, excessive breathiness, roughness, strain, pitch, or loudness), a pediatric otolaryngologist and then a speech-language pathologist should be consulted. Once the cause of the voice disorder is identified and any needed medical or surgical treatments identified and/or rendered, parents and caregivers can provide appropriate environmental and behavioral modeling to improve voice quality. With very young children and toddlers, indirect treatment procedures can be performed by instructing the parents. Both indirect and modified, direct treatment approaches can be used in a positive and play approach. Children as young as 3 years of age can typically participate in formal, appropriately focused voice therapy. At this age they can usually imitate various vocal tasks involved in voice therapy (e.g., pitch glides, sustained phonation, blowing bubbles, imitating vowel sounds at various pitches etc.) (Brehm, Weinrich & Kelchner 2019).

16. 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. Indirect treatments must specifically address the problematic voicing behaviors, and those behaviors beyond voicing, that exacerbate the voice concern. For hygienic voice therapy to be effective, the clinician must obtain a thorough intake history that identifies all the behaviors (e.g., vocal use, hydration, gastroesophageal or laryngopharyngeal reflux) that 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, games and reward systems that are meaningful to the child. Numerous app-based game and therapeutic approaches are available to be used in therapy. Direct treatment approaches can be modified for young children 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 (Brehm, Weinrich & Kelchner, 2019).

17. 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 a 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. Voice complaints of morning hoarseness and insomnia are symptoms consistent with reflux and emotional stress, respectively (Tepe et al., 2002). 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 (LeBorgne & Rosenberg, 2024).

18. 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 (LeBorgne & Rosenberg, 2024).

19. I have a high school athlete on my caseload with Inducible Laryngeal Obstruction (ILO) – What do I do?

Inducible laryngeal obstruction (ILO; formerly referred to as paradoxical vocal fold dysfunction or PVFD) occurs when the vocal folds involuntarily adduct during the inspiratory phase of breathing and create an obstruction in the airway. This condition can be found across the lifespan but is more commonly found in adolescents and young adults. Onset of symptoms may relate to physical exercise, laryngeal hyperreactivity, or emotions, though the cause may be due to multiple factors that are difficult to discern. When obstruction is observed during higher levels of physical exertion, it is referred to as exercise inducible laryngeal obstruction (EILO). 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 may 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 (Sapienza & Hoffman, 2022).

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 several 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 (Bergeron et al., 2018; Kelchner, Brehm, & Weinrich, 2014).

References

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