Therapy for Early Vocal Nodules in Children

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Answer

There are many therapy activities that would be suitable and efficacious to use for a 4-year old child with early nodules. However, there are those in the field that do not recommend starting intervention until the child is old enough to consistently change the behaviors which brought on the thickening of the vocal folds initially. It also depends on the child's cognitive abilities, maturation level and attention skills. This past year our clinic serviced several young children with nodules and each case was tailored to the child's abilities with the end results varying. Some children were better able to consistently change their vocal behaviors to initiate reduction of the vocal fold thickening.

It is beneficial to fully understand the anatomy and physiology that you are dealing with so you can address specific speech subsystem issues. The early nodule will cause an interruption in the movement of the vocal folds as they come together to close and then vibrate for voiced sounds. Thickening which occurs with early nodules causes the vocal folds to vibrate aperiodically, adding noise to the underlying voice signal. This noise is usually perceived as vocal hoarseness. In addition, subglottal pressure must build up underneath the vocal folds in order to maintain or increase the loudness of voice. Changing loudness and maintaining adequate loudness then becomes more challenging because the vocal folds are not fully closing (in some cases). The child will then attempt to maintain her/his normal loudness levels and then push muscularly to achieve this intensity level. This may cause other peripheral issues such as laryngeal muscle tension and breathing in coordination.

Therapy should focus on all the speech subsystems. You need to evaluate if there are respiratory, laryngeal or supralaryngeal concerns and then address each one in therapy. Possible respiratory issues could include increased loudness requiring higher lung volume initiations and greater lung volumes, decreased expirations effecting utterance length, increased breaths per minute interrupting speech and muscular tension associated with increased breath pressure maintenance. These possible respiratory issues may or may not be present, but that must be determined. If it is found that one or more of these symptoms are present then they must be addressed within therapy. In terms of activities, awareness of breathing and how it is accomplished would be the first task with a child this young. One example would be to use a pinwheel and ask the child to inhale and then exhale to make the pinwheel move. The child begins to see that there are two distinct phases of breathing. Then you can ask the child to gently make a vowel sound on the exhalation. These and more examples can be found in "Using Your Voice Wisely and Well: Vocal Awareness Activities for Children" by Pauline T. Flynn, Moya Andrews and Barbara M. Cabot. The publisher is Pro-Ed and it is in the second edition. There are other activity books by Moya Andrews available with excellent suggestions for voice therapy with children.

The laryngeal goals are most likely going to center around decreasing the vocal abuses and misuses such as screaming, loud talking, effect noises and character voices. Other misuses might include throat clearing and coughing. In these cases where these symptoms are observable, it may be prudent to determine if allergies are present and how they are being managed. Often times post nasal drip can cause chronic throat clearing. Again, begin with vocal awareness by instructing them about voiced and voiceless sounds, the anatomy of the vocal folds and the nodule using pictures, diagrams and play activities. Puppets are a fun way to demonstrate target voice production along with the voice you want to eliminate. Teaching the concepts of soft and loud can also be achieved through understanding and categorizing environmental sounds such as car horns, emergency vehicles, the wind blowing in the trees and any series of contrasting sounds which keeps the child thinking about loudness and reducing it!! Once you have achieved awareness then you may begin modifying the child's voice through behavioral therapy. One of our student clinicians used charts to help the child remember target voice. She had a large smiley face and every time the child made a target production she rewarded the child with a sticker to place on the smiley face. She also taught the child about water intake this way as well. She had a large empty glass of water and the child would color in lines in the glass every time they had a glass of water. This activity was carried on in the home too. Another area to observe and monitor is laryngeal tension and pushing. Make sure that you are deactivating muscles by stretching or other relaxation activities.

Supralaryngeal concerns might be lip and jaw tension, adequate oral opening, and appropriate oral and nasal resonance. You mentioned that you were completing oral motor exercises and that would help two elements of this disorder. Firstly it would help monitor and possibly reduce tension in the oral area as well as tongue and laryngeal tension and secondarily it would help with awareness of the articulatory structures that may or may not contribute to the voice quality. The ultimate goal in any of these activities is to work from awareness to modification to carry-over.

Selected References:

American Speech-Language Hearing Association. (2000). Guidelines for the roles and responsibilities of school-based speech-language pathologist. Rockville, MD: Author

American Speech-Language Hearing Association. (2003). IDEA and Your Caseload: A Template for Eligibility and Dismissal Criteria for Students Ages 3 to 21. Rockville, MD: Author

Boyle, B. (2000). Voice disorders in school children. Support for Learning, 15, 71-75.

Deal, R., McClain, B., & Sudderth, J. (1976). Identification, evaluation, therapy, and follow-up for children with vocal nodules in a public school setting. Journal of Speech and Hearing Disorders, 41, 390-397.

Flynn, P.T., Andrews, M.L., & Cabot, B.M. (2004). Using your voice wisely and well: Vocal awareness activities for children (2nd edition).

Bridget A. Russell is an Associate Professor at the State University of New York Fredonia and directs the Speech Production Laboratory in the Youngerman Centers for Communicative Disorders at the University. She has published in the Journal of Speech, Hearing and Language (JSHLR), Speech and Voice Review. She has presented over 70 peer reviewed presentations at national and international conferences on voice and respiratory disorders. Dr. Russell also has served as an editorial consultant for JSHLR, National Science Foundation (NSF) and DelMar Publishing Group. Dr. Russell's research interests include voice disorders in children and adults, professional voice, and respiratory disorders of speech production.