Question
I have an 8 year old girl with a history of whooping cough. She reportedly has had a "deep" voice since she began to speak. She has been in voice therapy since kindergarten. ENT reports, for 2 years in a row, of vocal nodules. He also recommends continued
Answer
When treating a child with vocal nodules there are many areas to consider before and during treatment. Age is a consideration factor. Nodules tend to disappear by the end of adolescence, especially in males and the symptoms of nodules in children, such as hoarseness, may be eliminated when provided information on vocal hygiene only (Pannbacker, 1999). This spontaneous healing does have much to do with cognitive and physical maturity. Many younger children are unconcerned with their voice and as they age it becomes more evident they need to change behavior as their peers, teachers and parents begin to notice the abnormality in perceptual voice qualities. Early researchers believed that treating the child larynx is not advised due to the fragility of the larynx (Von Leden, 1985). The timing of voice therapy also demonstrates that voice treatment is successful when it is recommended early or with recently formed nodules and surgery is more common for established or chronic nodule.
If the therapy has already commenced then focus should be placed on treatment concepts that are not abstract and require the ability to self-monitor during vocal production. Modification of approaches with children are essential for success. Vocal hygiene, should be addressed in the first few session, be educational not punitive and be composed of a discussion of "good" versus "bad" choices. Vocal hygiene should include education regarding hydration, behavioral modifications for abuse/misuse of the voice, and overall good vocal health. Other therapy recommendations would include education on diaphragmatic breathing, resonant voice therapy, and vocal function exercises. Compliance is an issue in your case. New therapy techniques should be implemented before discharge that include all speech subsystems, a systematic approach. Ultimately you are looking to achieve physical outcomes. The outcomes may include decreased vocal fatigue, less pain or effort when speaking, and increased efficiency in communicating with peers and teachers. These physical changes can be highly motivating for children to improve their vocal habits.
Ultimately, if no changes are appreciated within 6 months, after exhausting multiple therapy techniques, then discharge should be considered.
References
Pannbacker, M. (1999). Treatment of vocal nodules: Options and Outcomes. American Journal of Speech-Language Pathology, 8(3), 209-217.
Von Leden, H. (1985). Vocal nodules in children. Ear, Nose, and Throat Journal, (64), 473-
480.
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Dr. Bridget A. Russell received her B.A., M.A., and Ph.D. from the State University of New York at Buffalo. She is an Associate Professor at the State University of New York College at Fredonia. Her research interests are speech ventilation and cost of breathing, and voice/respiratory disorders affecting speech production.