Voice Disorders in Children Require a Team Approach

“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).

“I think that nodules in children are much less common than previously reported.”

—Melissa M. Statham, MD

Treatment

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.