Voice Disorders in Children Require a Team Approach
by Mary Beth Nierengarten
Although voice disorders in children are not new, recognition of the need to address and treat these disorders in many children is increasing. Experts say this is fueled by two recent developments: improvements in diagnostic technology tailored to better accommodate the smaller anatomy of children and greater awareness that voice disorders in childhood may have a larger and more long-lasting impact on a child’s life than previously recognized.
The increased understanding is also leading to more physicians completing fellowships in both pediatric and adult laryngology. Although the number of otolaryngologists who have completed such double fellowships is small—about 10, according to Albert Merati, MD, professor and chief of the laryngology service at the University of Washington Medical Center in Seattle—Dr. Merati believes these double fellowships are the future.
“Pediatric voice care has been neglected for decades, or at least lost behind truly pressing issues like pediatric airway surgery,” Dr. Merati said. “If we knew for sure what the impact of having a disordered voice had on kids, that would help us motivate and educate families. We need the research to show us how to answer the question: Tell me why it matters?”
Voice disturbances in children are not uncommon. According to statistics cited by the American Speech-Language-Hearing Association (ASHA), hoarseness occurs in 6 to 23 percent of school-aged children. Although they were once thought to be a condition that could be outgrown, there is increased recognition that vocal disturbances in children can create lifelong communication and other problems if left untreated.
“In the past, practitioners have downplayed pediatric voice disorders because they believed that children would grow out of it, or if they would just stop yelling on the playground the hoarseness would go away,” said Shannon M. Theis, PhD, CCC-SLP, clinical assistant professor of communicative disorders at the University of Wisconsin School of Medicine and Public Health–Voice and Swallowing Clinics in Madison, Wis. “Now, we understand that pediatric voice disorders can have a significant effect on a child’s school performance, self-esteem and communicative effectiveness.”
According to Kittie Verdolini Abbott, PhD, professor of communication science and disorders at the University of Pittsburgh, who has helped treat children with voice disorders, some of the difficulties these children face include not being called on in class, being excluded from play, missing school due to voice therapy and behaving more aggressively.
A 2008 study found that chronic dysphonia in children negatively affected their lives by inviting negative attention and limiting their participation in important events (J Voice. 22(2):197-209).
Vocal disorders often refer to hoarseness, which is the most common symptom. According to Gayle Woodson, MD, professor and chair in the division of otolaryngology-head and neck surgery at Southern Illinois University School of Medicine in Springfield, Ill., hoarseness may be present at birth because of a congenital problem such as vocal fold paralysis or a laryngeal web but often presents later due to acquired vocal fold lesions or laryngitis.
“In my practice, the most common pediatric voice disorder by far is vocal nodules or calluses on the vocal folds. These children speak or scream loudly, and the cause is assumed to be vocal abuse,” she said. “Once nodules have developed, it is difficult to speak softly and so children have to speak loudly.”
Although vocal nodules are typically said to be the cause of pediatric voice disorders, Melissa M. Statham, MD, assistant professor of otolaryngology-head and neck surgery at Emory University School of Medicine in Atlanta, said that in her experience, vocal nodules are an uncommon diagnosis. “I think that there are several reasons ENT physicians have called vocal fold lesions in children nodules,” said Dr. Statham, who holds a double fellowship in adult laryngology and pediatric otolaryngology, “but, in reality, now that we have higher resolution imaging, better diagnostic tools and improved understanding of the physiology of the vocal folds in children, I think that nodules in children are much less common than previously reported.”
Many children with voice disorders have an underlying medical condition, such as asthma or acid reflux, which makes them cough a lot, and the coughing induces traumatic injury to the vocal folds, she said. “If you’re actually able to get close enough to see the vocal fold lesions in these children, they often have altered mucosal wave and they commonly have more firm, fibrous masses in their vocal folds,” she said, adding that, in contrast, nodules do not alter mucosal wave.
Although vocal fold lesions comprise the most common causes of voice disorder, other causes must be considered in order to make an accurate diagnosis. These include chronic laryngitis due to laryngopharyngeal reflux or rhinosinusitis and laryngeal papillomatosis. Rarer conditions include hemangioma, laryngeal webs, post-surgical or trauma issues (subglottic/glottic stenosis), neurogenic disorders (vocal fold paresis or paralysis), paradoxical vocal fold motion and functional voice disorders.
The life-threatening nature of some of these conditions is a reminder that pediatric voice disorders should not be dismissed as unimportant, Dr. Theis said.
For accurate diagnosis, Scott Rickert, MD, assistant professor of pediatrics and otolaryngology at New York University Langone Medical Center, where he is also director of the Pediatric Voice Center, emphasized the importance of a multidisciplinary team approach that includes a visual examination with videostroboscopy, a thorough pediatric voice history, a quality of life assessment and assessment by a speech language pathologist (SLP).
Although the use of videostroboscopy can be more challenging in children, it is particularly recommended to rule out any obstruction that may eventually interfere with breathing, such as papilloma. According to Dr. Woodson, advances in videostroboscopy that permit the use of thinner endoscopes have helped provide more light to more accurately examine children’s smaller vocal folds. To help quantify the degree of hoarseness, a Pediatric Voice Handicap Index (pVHI) has been developed, similar to the Voice Handicap Index (VHI) used in adults (Int J Pediatr Otorhinolaryngol. 2007;71:77-82).
—Melissa M. Statham, MD
For most children with vocal disorders caused by vocal fold nodules, voice therapy is the mainstay of treatment. According to Dr. Rickert, voice therapy can be effective in children as young as five years old. The key, he said, is to individualize care using an approach that includes the patient, the patient’s family, the pediatric laryngologist, the pediatric SLP and the pediatrician.
Traditional approaches to voice therapy may need to be altered to meet the needs of children and to improve compliance. According to Dr. Theis, traditional voice treatment approaches that focus on vocal hygiene, implementing worksheets and reducing “abusive” behaviors such as yelling have limited effectiveness. She recommends the following approaches to improve a child’s vocal technique:
- vocal hygiene and hydration that focus on directly improving vocal quality and establishing intrinsic motivators to encourage compliance, with an emphasis on education rather than admonishment;
- behavioral voice treatment approaches that focus on improving vocal technique using child-friendly language and including the child’s caregiver in the sessions to help facilitate practice;
- resonant voice treatment that focuses on achieving a continuum of oral sensations and easy phonation from basic speech productions through conversational speech; and
- diaphragmatic breathing, lip trills, stretching and neck/laryngeal massage that focus on improving voice quality and decreasing vocal effort and fatigue by improving breath support, local fold closure and forward focus resonance and decreasing excess muscle tension.
Dr. Verdolini Abbott also emphasized the ineffectiveness of traditional voice therapy that focuses on telling children “not to abuse their voice.” She and her colleagues have developed a voice therapy program based on research they’ve done on the biomechanics of phonation, learning and compliance in children. Called “Adventures in Voice,” the game-based program is geared for children between the ages of four and 11 and uses video games and other technology to teach them how to produce a normal and loud voice safely rather than restricting their phonation.
One of the tenets of the program is that voice patterns used by children reflect what they are exposed to in their families and with their peers, often at school. “We are looking at socially driven voice patterns,” she said. “Many of the voice patterns used by children are used by the rest of the family.”
Because school represents the environment in which a child has his or her most active social life, an aim of Dr. Verdolini Abbott and her colleagues is to incorporate activities from the program in the school setting. However, she emphasized the challenge of convincing schools that voice problems can affect a child’s school performance, because the majority of speech pathologists who work in the schools have limited knowledge of voice therapy. When referring their patients for voice therapy, she encourages otolaryngologists to find a speech pathologist who has specialized in voice and pediatric voice. “If you refer to a generic speech pathologist, they won’t know what to do,” she said.
According to Dr. Verdolini Abbott, a permutation of the “Adventures in Voice” program is currently being investigated in a clinical trial led by chief investigator Christopher Hartnick, MD, sponsored by the National Institutes of Health and conducted through Harvard Medical School. She said that, to date, no clinical trial has been reported on voice therapy in children.
For children who require additional therapy, medical treatment or surgical intervention are potential options. Dr. Woodson emphasized, however, that surgery is not recommended as first-line treatment for vocal nodules in children because this may lead to scarring that can permanently alter the voice. In cases such as papilloma, for which laryngeal surgery is required, she emphasizes following phonosurgical principles to minimize the impact of the surgery on the voice.
Dr. Statham said there are some situations in which surgery may be warranted. “Surgery to remove vocal fold lesions is an elective surgery done to improve quality of life and, therefore, you want to be very thoughtful about it,” she said. Given that advice, she said she would consider surgery in a child with a deep vocal fold scar that may be congenital. She also recommended limiting this type of surgery to children who are mature enough to be compliant to post-surgical care such as voice rest and therapy.
The use of innovative surgical approaches for treating voice disorders in children is still an emerging area, Dr. Statham said, adding that she would like to see the more sophisticated techniques currently offered to adults adapted to children.
“As a field, otolaryngology has not pushed the envelope with some of these procedures in children.” she said.