"How long has your son had a hoarse voice?" the clinician asked. "Oh, he has always sounded like that, ever since he was a baby," the mom replied. In addition to demonstrating severe dysphonia, the 10-year-old was experiencing episodes of shortness of breath. After the child's medical/speech-language voice evaluation, the otolaryngologist diagnosed juvenile recurrent respiratory papillomatosis that involved true vocal folds and the supraglottic larynx. The lesions were beginning to obstruct the boy's airway during certain activities. The condition, present since birth, required immediate medical-surgical treatment and a comprehensive, detailed plan for vocal hygiene and voice care.
Voice difficulties in children are commonly the result of vocal nodules, which are generally attributed to vocal misuse, overuse or phonotrauma. But this case was clearly different. The young patient went several years without a proper medical diagnosis or care for his voice disorder. It was unclear to the treating team why his family—and perhaps the child's pediatrician—had waited to seek a diagnosis.
This vignette illustrates an important consideration: The human voice involves complicated physical, perceptual and psychosocial-emotional systems. In fact, the presence of a voice disorder may signal other childhood health and behavioral issues, particularly in younger children with smaller airways. In making decisions about evaluating and treating children with voice difficulties, speech-language pathologists may want to look beyond the usual factors—vocal use and hydration—to other factors, such as the child's general health (including medical history, current medical conditions and medications), diet, activity level, psychosocial and emotional issues, recreational drug use, family dynamics, and environment.
Basic voice difficulties
With most children, basic voice treatment—"don't yell" and "drink more water"—will help treat the nodules caused by phonotrauma. The term phonotrauma replaced the term "vocal abuse" about 15 years ago, and is intended to more appropriately label the impact of certain vocal behaviors on vocal fold tissue and any subsequent change in voice. But the term also can be a bit confusing for school-age children and their parents, as "trauma" may imply some (intentional) infliction of an injury. When asking about vocal behaviors or suggesting alternative/substitute behaviors, clinicians may consider asking about patterns of voice use, voice overuse (or underuse), vocal enthusiasm or other similarly neutral terms.
Voice overuse may be a sign of an exuberant, outgoing child, or an indication of poor self-monitoring/control, lack of social skills, bullying or family dynamics. Only with a careful voice evaluation involving both the child and parent/caregiver will the clinician discern these issues and implement appropriate interventions. Specific vocal behaviors that typically need attention include speaking too loud, long or fast; using a pitch that is too high or too low; frequent yelling, shouting or screaming; unusual vocal noises; excessive or unnecessary coughing or throat clearing; and singing outside of a natural range. (Nowhere is this last behavior more apparent than on the many television shows designed to identify new "stars," some of whom use extreme vocal styles to get attention.)
Whatever the vocal behavior, the result is that the vocal folds collide with greater tension and force. Over time there may be an inflammatory response and ultimately the formation of nodules. Why some children with seemingly similar vocal behaviors develop nodules and others do not is unknown. Perhaps some other tissue irritant—digestive acids, for example—or genetic component is at work.
Moreover, the irritation may cause bilateral lesions, one of which may be a cyst with an opposing area of edema. Nodules almost always form at the juncture of the anterior one-third/posterior two-thirds of the vocal fold edge, but they may not appear symmetrical, making an accurate diagnosis difficult. If a child with "nodules" adheres strictly to a vocal hygiene program with limited results, a second examination of the vocal folds may be warranted.
Treatment for nodules includes emphasis on two different aspects of voice health: behavior changes and increased hydration.
In providing behavioral interventions, SLPs should include education for the child, parent or caregiver, and others in the child's life—including siblings, teachers, choir directors, coaches—about why the child's behaviors are affecting the vocal folds and how the child and communication partners can help change the behaviors.
Some specific voice use suggestions include:
- Turn down the vocal volume (actually pretend to turn down a dial) and ask parents to model appropriate volume.
- Ask the child to get closer (the same room as the parent) to make requests or share information.
- Teach the child how to increase volume safely by "cheering" or yelling at a lower frequency level where, theoretically, vocal folds are more lax and shorter and less susceptible to impact from phonation.
- Take voice naps—times during the day when talking time is limited.
- Substitute behaviors such as sipping water and using a hard swallow for throat clearing.
- Substitute sounds such as a lip buzz or whistle for harsh or rough sounds made during play.
- Use an easy onset, rather than a hard attack, and speak softly, as if you were telling a secret.
- Reduce background noise.
- Don't use earbuds—or at least turn down the volume—when listening to music.
- Anticipate noisy circumstances—for example, parties and sports events—identify vocal overuse "triggers," and rehearse the strategies listed above.
Hydration—drinking water-based beverages—improves the lubrication of the vocal folds by raising internal humidity and thinning out local laryngeal secretions that can help reduce friction during vibration of the vocal folds. A component of the recommendation "drink more water" must include instructions to reduce intake of any caffeinated or carbonated beverages.
The targeted amount of water appropriate for the younger child needs to account for any medical and medication concerns. "Peeing pale" is a useful guide for adults and may help children and their parents gauge if the child is getting enough water. The recommendation for older children is the same as for adults (up to 64 ounces per day) and again is related to weight, medications, athletic activity and other vocal use, such as singing. Eating water-rich fruits and vegetables can also help increase hydration. Use of interesting, colorful water bottles (after securing permission from the school) can be additional incentive for the younger child to cooperate. It is also helpful if the family adopts a "more water, less soda" habit.
The child's medical history—as in the opening vignette—may provide clues to other factors causing voice difficulties. More extensive treatment may be required in these cases.
Pollutants and airborne allergens are associated with greater numbers and severity of sinus, respiratory and related allergy conditions, which may contribute to the development of a voice disorder and affect its care. A child's environment exposure is determined by where the child lives (urban, suburban or rural region); local pollution; in-home pollution; and personal immune responses. Family education about the impact on vocal health from elevated levels of environmental pollution and airborne allergens—available in local weather alerts—is important.
In-home pollution, such as cigarette smoke, can be more difficult to address. Family members who smoke should understand the effects of primary and secondhand tobacco smoke exposure on respiratory and laryngeal disease. Evidence documenting these effects is compelling and readily available. Possible exposure to or use of other inhaled substances such as marijuana also needs to be addressed.
Allergic reactions to environmental allergens or foods can create symptoms that affect the larynx. Increased nasal congestion and drainage, coughing and throat clearing all may produce inflammation of the vocal folds. The most obvious way to reduce allergic reactions is to avoid the known allergens. If avoidance is not possible—if the child is allergic to plants and weeds or animal dander—pediatricians and allergists may recommend nasal steroids or antihistamines. Antihistamines are dehydrating, so children taking them should be encouraged to increase fluid intake.
The use of cool mist humidifiers increases the moisture in the air, which can decrease drying effects and keep excess mucus thinner and more easily cleared—and decrease severe coughing and throat clearing. If you are treating a child with suspected—but not confirmed—allergies for a voice disorder, encourage the parents to speak to the child's pediatrician about allergy testing to identify specific allergens and find a treatment that has the least potential effect on vocal health.
Asthma medications also may affect vocal health negatively. Environmental allergens and illness, along with other factors, may trigger asthma, which is caused by a swelling of the lining of the bronchi and bronchioles and spasms of the smooth muscle of these passages. Research has shown that consistent use of inhaled asthma medication (corticosteroids) is associated with increased hoarseness due to dryness and the development of candidiasis (thrush) in the airway.
Other prescription medications may have systemic dehydrating effects. When dehydration appears to be a continuous concern despite increasing hydration through fluid intake, you may want to ask parents for the names and dosages of the child's medications and explore their side effects (especially "dry mouth") and whether increased fluid intake is recommended. The SLP may consult with a physician about these side effects and encouraging the child to drink more. Other medications, such as those used in the treatment of attention deficit hyperactivity disorder, also may be associated with motor (vocal) tics.
The effects of gastroesophageal or laryngopharyngeal reflux often can be viewed during a laryngoscopic examination. The vocal folds may appear inflamed, filled with fluid, red, and covered with thick mucus. There may be edema or pachydermia—a granular formation—on the interarytenoid space. An otolaryngologist observing these conditions may prescribe an anti-reflux medication, which can help reduce acid reflux that finds its way to the laryngeal region. If parents seem wary of medicating their child, the SLP can encourage medication compliance and provide guidance on the causes of reflux and behavioral changes that may reduce it. The goals of these changes are to reduce pressure on the lower esophageal sphincter in the abdominal area and to avoid foods and activities that may weaken or allow that sphincter to open easily.
SLPs may want to recommend that children:
- Avoid eating large amounts of food two to three hours before bedtime. This recommendation can be difficult for families who have children in extracurricular evening activities. Families should be strongly encouraged to give the child a very small, nonfat meal if the child is eating close to bedtime.
- Sleep with the head of the bed elevated.
- Reduce intake of known acid producers, such as citrus- or tomato-based products, caffeinated or carbonated beverages, onions, garlic, high-fat foods and chocolate.
- Maintain an appropriate weight.
- Wear clothing that fits loosely around the waist.
Eosinophilic esophagitis is another gastrointestinal disorder that can affect a child's voice and require an intensive vocal health care regimen. Eosinophils are a form of white blood cells that can become inflamed in response to food, stomach acid or allergens. The laryngeal symptoms associated with the condition include chronic coughing and throat clearing, a globus sensation, and voice change. Assessments to differentiate eosinophilic esophagitis from reflux include impedance monitoring, pH probe testing, esophagogastroduodenoscopy, upper gastrointestinal series and biopsy of the esophagus. Treatment is similar but involves a multi-specialty medical (otolaryngology, gastroenterology and hepatology), dietary and speech-language approach that may include proton pump inhibitors, dietary changes, and steroids. Vocal hygiene is essential to achieve and maintain vocal health and to prevent additional voice problems.
Vocal difficulties in children are rarely caused by something as serious as recurrent respiratory papillomatosis. However, SLPs should always consider causes beyond phonotrauma, especially if the child carefully follows the standard protocol of voice rest and hydration without significant improvement. It's possible that because the child's respiratory papillomatosis had been present since his birth, his parents and physician did not consider it abnormal for this particular child. It is common clinical knowledge that pediatric voice disorders are under-referred, underevaluated and undertreated, but perhaps they are under-recognized as well.
In addition, parents and professionals view pediatric voice disorders as having no educational impact—unlike speech and language disorders—so they tend to be a low priority. If a clinician advocates for a student's voice evaluation and treatment, it can lead to complicated "who pays for it?" issues in the public school systems and, accordingly, school personnel in a position to recommend evaluation may hesitate to do so. SLPs are in a unique position to help identify and evaluate children with voice disorders and advocate for appropriate treatment.
The authors acknowledge the contributions of Janet Middendorf, Janet Beckmeyer, Barbara Weinrich, Stephanie Zacharias and Alessandro deAlarcon, members of the Center for Pediatric Voice Disorders Team, Cincinnati Children's Hospital Medical Center.