November 23, 2010 Features

Pediatric Voice Disorders: Evaluation and Treatment

Pediatric voice disorders typically have been blamed on vocally "abusive" behaviors, and many practitioners have tended not to provide intervention because they believed that children would "grow out of it." However, changes in pitch, loudness, and overall vocal quality tend to interfere with communicative abilities. Recently, research has focused on pediatric voice disorders and the effects of a voice disorder on a child's life. It has been reported that children and adolescents felt that their voice disorders resulted in negative attention and limited their participation in activities (Connor, Cohen, Theis, Thibeault, Heatley, & Bless, 2008).

Incidence rates of pediatric voice disorders range from 6% to 23% (Maddern, Campbell, & Stool, 1991), with more than 1 million children in the United States affected by chronic dysphonia (Gumpert, Kalach, Dupont, & Contencin, 1998). Childhood dysphonia is a broad condition and can be difficult to quantify and study; however, several studies have shown that voice disruptions negatively affect how children are perceived both by adults and by their peers (Ruscello, Lass, & Podbesek, 1988; Lass, Ruscello, Stout, & Hoffmann, 1991; Lass, Ruscello, Bradshaw, & Blankenship, 1991). Although voice disorders are common in the pediatric population and have recently been gaining more attention, there is still a lack of information available to clinicians regarding evaluation and treatment of pediatric voice disorders.

Shannon Theis performs a flexible fiberoptic endoscopy on a young patient

SLP Shannon Theis performs a flexible fiberoptic endoscopy on a young patient.

Laryngeal Development 

The developing larynx and vocal tract change significantly from infancy to adulthood. Although the pediatric larynx differs from the adult larynx, clinicians often consider it as a miniature version of an adult's larynx when treating pediatric dysphonia. When an infant is born, the larynx is positioned very high in the neck, a location that facilitates the coordination of respiration and swallowing while feeding (Gray, Smith, & Schneider, 1996).

As the child grows, the larynx descends; the movement does not necessarily affect phonation, but it does affect the resonance of the vocal tract. As the infant's vocal tract continues to grow, the frequency of the vocal tract formants decreases, as does the fundamental frequency (Gray, Smith, & Schneider, 1996). Therefore, one of the most important features in the developing pediatric voice is the change in pitch as children get older. The laryngeal structure also changes. It has been shown that laryngeal growth is related to overall body growth. This growth accelerates from birth to age 3, then decelerates, then enters a rapid growth phase during adolescence and puberty, particularly in boys (Gray, Smith, & Schneider, 1996). Until puberty, the larynx is similar in size for boys and girls, and voices do not differ greatly (Maddern, Campbell, & Stool, 1991).

Causes of Disorders 

Changes in the structure or function of the pediatric larynx can lead to dysphonia, and a child can present with a voice problem for a number of different reasons. A thorough review of pediatric voice disorders is beyond the scope of this article; in general, however, childhood dysphonia can be broadly classified into several categories: infectious, anatomic, congenital, inflammatory, neoplastic, neurologic, and iatrogenic (McMurray, 2003).

Vocal fold nodules are one of the most common forms of pediatric dysphonia (Maddern, Campbell, & Stool, 1991) and are considered inflammatory. Studies have estimated that the incidence of vocal fold nodules as the cause of pediatric dysphonia ranges from 38% to 78% (Gray, Smith, & Schneider, 1996). Vocal fold nodules are defined as swelling (usually bilaterally) in the mid-membranous portions of the true vocal fold that interferes with glottic closure and vocal fold vibration (Heman-Ackah, Kelleher, & Sataloff, 2002). Vocal nodules impede the normal vibratory pattern of the vocal folds and present what we hear acoustically as hoarseness. Vocal nodules are the most common—but not the only—cause of pediatric dysphonia; therefore, a thorough assessment and diagnosis are essential in the evaluation and treatment of pediatric voice disorders.

It is important to note that stridor (noisy inhalation or any other type of airway distress) is an important symptom to differentiate in pediatric voice disorders. Any type of voice change that is associated with airway symptoms or swallowing difficulties should be evaluated and treated immediately because it may be indicative of a potentially life-threatening condition (McMurray, 2003).

Evaluation 

Evaluation of pediatric dysphonia requires a multidisciplinary approach to assess vocal function completely. A combined effort between a pediatric otolaryngologist and voice-trained speech-language pathologist is required as the first part of a child's care, with referrals to other medical specialties as needed. A complete pediatric voice evaluation involves many different components including a thorough medical history, acoustic and aerodynamic measures, perceptual judgments of voice quality during spontaneous speech, laryngeal visualization, and medical examination by a physician (McMurray, 2000).  

Medical History

It is imperative to obtain a thorough medical history as the first step in the voice evaluation to understand the onset, course of the problem, surgical history, and associated problems with breathing or swallowing. The specific issues of the dysphonia can aid in differential diagnosis. For example, intermittent dysphonia that is worse in the morning than at night may suggest gastroesophageal reflux. Persistent dysphonia with airway distress may suggest respiratory papillomatosis. Using child-friendly language to obtain the older child's perspective of symptoms is an important step, as parents are often unaware of—and sometimes surprised by—their child's response. For example, asking about "sour burps" or "mini throw-ups" when assessing reflux-related symptoms are terms that pediatric patients can understand and can lead to valuable information regarding their symptoms.

Perceptual Judgments 

Two formal perceptual assessments commonly used among clinicians to rate voice quality are the GRBAS scale (Grade, Roughness, Breathiness, Asthenicity, Strain) and the CAPE-V (Consensus of Auditory Perceptual Evaluation of Voice). Both scales describe the severity of the voice disorder and its attributes.

However, perceptual rating of voice quality has been shown to be inconsistent across listeners (Millet, 1998). Although the "ear" is an important instrument in analyzing voice quality and always should be incorporated into the voice evaluation, objective measures, such as acoustic and aerodynamic assessments, offer supplemental unbiased documentation of voice change over time (Bless, Hirano, & Feder, 1987).

Acoustic and Aerodynamic Assessment 

Acoustic measures can include quantification of fundamental frequency, vocal intensity, frequency and amplitude perturbation (jitter and shimmer), and signal-to-noise ratio (Case, 1999). Aerodynamic measurements of airflow and laryngeal airway resistance also are often calculated (Stemple, Glaze, & Klaben, 2000), although obtaining these measurements can be challenging in the pediatric population.

Proper evaluation and treatment of children with voice disorders requires reliable, quantitative recording and voice analyses for thorough assessment as well for measuring treatment outcomes following behavioral and/or surgical management. Campisi et al. (2002) recently established a database of pediatric normative values for use with the Multidimensional Voice Program (MDVP) based on 94 control subjects ages 4 to 12 years; this database increases the accessibility of computerized voice analysis system in pediatric dysphonia.

Laryngeal Visualization 

Endoscopic examination for laryngeal observation is essential in diagnosing pediatric voice disorders; an accurate diagnosis is otherwise virtually impossible (Hirschberg et al., 1995). According to ASHA's position statement on the use of endoscopy by speech-language pathologists (2008), endoscopy is included within the scope of practice for SLPs. Young children often are not able to tolerate stroboscopy with a rigid endoscope; therefore, a flexible endoscope is used (Chait & Lotz, 1991). The endoscopic evaluation helps assess the upper airway, laryngeal function and structure, and velopharyngeal function.

Adequately preparing a child to be as compliant as possible during this invasive procedure requires a great deal of skill. Typically, both child and caregiver have a great deal of anxiety. Time should be allowed to prepare the child and the family for the procedure in order to obtain the best possible images and exam, which will facilitate appropriate surgical, medical, and behavioral management. It is not enough to get a quick glimpse of the larynx—the goal is to obtain the most comprehensive examination possible with the least amount of discomfort and anxiety. Also, it is likely that the child will need to repeat the endoscopy in the future, so the experience should be as positive as possible to aid in future compliance.

Voice Treatment 

Depending on the diagnosis, a number of treatment options are available for pediatric dysphonia. Treatment for vocal fold cysts often entails surgical removal from the submucosal layer of the vocal folds with as little disruption as possible to the surrounding tissues and mucosae. In recurrent respiratory papillomatosis, the voice and airway are both affected; therefore, surgical intervention is used to maintain an adequate airway while preserving the structures necessary for phonation (McMurray, 2000). Behavioral voice treatment is generally the recommended treatment for pediatric vocal nodules.

Traditional voice treatment typically focuses on vocal hygiene, worksheets, and reducing "abusive" voice behaviors, such as yelling. These approaches, however, have limited effectiveness. The traditional approach to voice treatment presents several problems:

  • The negative connotations of terms such as "vocal abuse" may cause children to feel as if they have done something wrong, but they see their friends engaging in the same type of behaviors without consequences.
  • Children are not typically motivated to change behavior based on traditional behavioral approaches.
  • Many children have been dysphonic since they began speaking, and therefore have no baseline. Adults, conversely, generally have experienced a "normal" voice and are typically motivated to return to that voice, but children may not have that same motivation.

Vocal hygiene and hydration have a role in pediatric voice treatment, but they should not be the only goals. Treatment should focus on directly improving vocal quality and establishing intrinsic motivators for the child to comply with treatment activities.

A variety of behavioral voice treatment approaches that focus on improving vocal technique can be used successfully with children. Typically, techniques used with children are similar to those used with adults, with some modifications: using child-friendly language, incorporating the child's caregiver into the sessions to help facilitate home practice and carry-over, and scheduling additional sessions to achieve treatment goals.

Resonant voice treatment is a common approach to pediatric voice treatment, with the goal of
achieving easy phonation through a barely abducted/barely adducted glottal configuration to produce high amplitude of vibration with low-impact stress (Verdolini, 1998). Treatment focuses on achieving a continuum of oral sensations and easy phonation, beginning with basic speech productions through conversational speech.

Voice treatment with children also can target diaphragmatic breathing, lip trills, stretching, and neck and laryngeal massage. Vocal function exercises also can be utilized with the pediatric population (Stemple, Glaze, & Klaben, 2000).  The goals of treatment are to improve breath support, decrease excess muscle tension, improve vocal fold closure, and improve forward focus resonance, all in an effort to improve voice quality and decrease vocal effort and fatigue.

Voice treatment often focuses on concepts that are abstract for both adults and children and require the ability to self-monitor during productions. Therefore, approaches must be modified to be successful with children. Vocal hygiene, which is typically addressed in the initial session, should be presented as education rather than admonishment, with a discussion of alternatives rather than "good" versus "bad" choices. Vocal hygiene should include hydration discussions, behavioral modifications for reflux, and overall good vocal health.

Diaphragmatic breathing, resonant voice therapy, and vocal function exercises can be implemented easily with children using simple modifications to encourage motivation and skill acquisition. Finally, compliance can be an issue with voice treatment programs, but physical outcomes—such as a decrease in vocal fatigue, less pain or effort with speaking, and increased communicative effectiveness with peers and teachers—can be highly motivating to children.

Shannon M. Theis, PhD, CCC-SLP, is a clinical assistant professor of communicative disorders at the University of Wisconsin-Madison and senior clinical SLP in the voice and swallow clinics in the Division of Otolaryngology at the University of Wisconsin School of Medicine and Public Health. Contact her at theis@surgery.wisc.edu.

cite as: Theis, S. M. (2010, November 23). Pediatric Voice Disorders: Evaluation and Treatment. The ASHA Leader.

A Case of Childhood Dysphonia

A fifth-grade boy presented in the clinic with a several-year history of dysphonia. His mother reported that his grades at school had been dropping because he did not feel comfortable participating in class discussions and was self-conscious during oral reading tests. He would often lose his voice by the end of the school day or experience so much vocal fatigue that he wasn't able to interact with his peers. He was receiving school-based voice treatment that focused solely on voice rest and vocal hygiene behaviors, with little to no benefit noted. His mother reported that he also would get angry easily and have "meltdowns" due to his communication challenges.

A full voice evaluation by a pediatric voice-trained speech-language pathologist and pediatric otolaryngologist was needed for appropriate medical and behavioral intervention to help with communicative abilities. The multidisciplinary approach was successful. The evaluation indicated laryngeal erythema and edema and large vocal fold nodules, which were interfering with vocal fold vibration and complete glottic closure. Voice treatement was initiated, as was medical management for laryngopharyngeal reflux. The patient achieved significantly improved vocal quality following appropriate evaluation and treatment: his mother reported improved academics, more outgoing behaviors, and greater interaction in the classroom and with his peers.



Resources



Division 3, Voice and Voice Disorders

Members with an interest in the assessment and treatment of voice disorders can join with colleagues in Special Interest Division 3, Voice and Voice Disorders.

For more information, visit Division 3's webpage.



References

American Speech-Language-Hearing Association. (2008). Use of Endoscopy by Speech-Language Pathologists: Position Statement [Position Statement]. Available from www.asha.org/policy

Bless, D. M., Hirano, M., & Feder, R. J. (1987). Videostroboscopic evaluation of the larynx. Ear, Nose, and Throat Journal, 66(7), 289–296.

Campisi, P., et al. (2002). Computer-assisted voice analysis: Establishing a pediatric database. Archives of Otolaryngology–Head & Neck Surgery, 128(2), 156–60.

Case, J. (1999). Technology in the assessment of voice disorder. Seminars in Speech and Language, 20, 169–184.

Chait, D. H., & Lotz, W. K. (1991). Successful pediatric examinations using nasoendoscopy. Laryngoscope, 101(9), 1016–1018.

Connor, N.P., Cohen, S.B., Theis, S.M., Thibeault, S.L., Heatley, D.G., & Bless, D.M. (2008). Attitudes of children with dysphonia. Journal of Voice, 22(2), 197–209.

Gray, S.D., Smith, M.E., & Schneider, H. (1996). Voice disorders in children. Pediatric Clinics of North America, 43(6), 1357–1384.

Gumpert, L., Kalach, N., Dupont, C., & Contencin, P. (1998). Hoarseness and gastroesophageal reflux in children. Journal of Laryngology and Otology, 112, 49–54.

Heman-Ackah, Y.D., Kelleher, K., & Sataloff, R.T. (2002). Inferior glottic ridges that prevent vocal fold closure. Ear, Nose, and Throat Journal, 81(4), 207–209.

Hirschberg, J., et al. (1995). Voice disorders in children.Inernational Journal of Pediatric Otorhinolaryngology, 32 Suppl, S109–125.

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Lass, N.J., Ruscello, D.M., Bradshaw, K.H., & Blankenship B.L. (1991). Adolescents' perceptions of normal and voice-disordered children. Journal of Communication Disorders, 24(4), 267–274.

Lass, N.J., Ruscello, D.M., Stout, L.L., & Hoffmann, F.M. (1991). Peer perceptions of normal and voice-disordered children. Folia Phoniatrica, 34, 29–35.

Maddern, B.R., Campbell, T.F., & Stool, S.(1991). Pediatric voice disorders.Otolaryngologic Clinics of North America, 24(5), 1125–1140.

McMurray, J.S. (2000). Medical and surgical treatment of pediatric dysphonia.Otolaryngologic Clinics of North America, 33(5), 1111–1126.

McMurray, J.S. (2003). Disorders of phonation in children. Pediatric Clinics of North America, 50(2), 363–380.

Millet, B.D. (1998). What determines the differences in perceptual rating of dysphonia between experienced raters? Folia Phoniatrica et Logopaedia, 50, 305–310.

Ruscello, D.M., Lass, N.J.,&  Podbesek, J. (1988). Listeners' perceptions of normal and voice-disordered children. Folia Phoniatrica, 40, 290–296.

Stemple, J.C., Glaze, L.E., & Klaben, B.G. (2000). Clinical voice pathology, theory and management (3rd ed.). Canada: Singular Publishing.

Verdolini, K. Resonant voice therapy. (1998). In K. Verdolini (Ed.), National Center for Voice and Speech's Guide to Vocolology. Iowa City, Iowa: National Center for Voice and Speech.



  

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