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Childhood Vocal Nodules:Concerns and Management

By: Julie Phillips

What are Vocal Nodules?

Small benign swellings/ Edema of the subepithelial tissue Along margins of the

vocal cords At the junction of the

anterior and middle thirds

Usually bilateral Pale to pink in color

Usually matching the color of the vocal cords

(Von Leden, 1985)

What Causes Nodules in Children? Vocal Trauma

Loud talking/screaming Playground Singing Cheerleading Coughing/Sneezing Crying Laughing/Cheering Sound Effects/Animal

Noises Dehydration

Medical, Physiological, and Psychological Risk Factors

Personality Aggressiveness,

frustration and anxiety Affective Disorders

ADD, ADHD Family Habits Asthma/Allergies URI Gastric Reflux Stress

(Bowen, 1997)

Frequency of Occurrence

Vocal Nodules are the most common laryngeal pathology that SLPs see in schools

Over an estimated 1 million children have vocal nodules

Rank 2nd to inflammatory conditions for causing hoarseness in children

Occur more frequently in children than adults Boys 3x more likely (From 5-10 years old)

(Pannbacker, 1999)

Misdiagnosis

Prevalence data may be inflated due to misdiagnosis Chronic hoarseness is often mistakenly attributed to

vocal fold nodules Reflux Laryngitis (American Academy of Otolaryngology, Head and Neck Surgery)

Polyps Intracordial cysts Contact ulcers Papillomas Squamous cell carcinomas

(Pannbacker, 1999)

The Controversy Begins

SLPs and ENTs alike have had much difficulty agreeing on how to deal with vocal nodules in children

Management Options Include:

1. Voice treatment2. Surgical Removal3. Voice treatment

and surgical removal

4. No Treatment

(Allen et al., 1991)

Some Questions to Consider

Should Vocal Nodules in Children be Treated Differently from those in Adults?

When should Surgical Removal be Considered? Or Shouldn’t It?

When do Nodules Resolve Spontaneously in Children? How?

How much is Treatment Necessary? How Frequently?

(Koufman, n.d.)

Other Things to Consider

Age of child Duration of the nodule Presence/absence of symptoms Response to previous Tx attempts Choice of treatment

SLP, ENT, and child/caregiver preference

Pannbacker, 1999

Age

Nodules tend to disappear by the end of adolescence Especially in males Hoarseness may be eliminated when provided

information on vocal hygiene (Pannbacker, 1999)

However, many young children are unconcerned with their voice

Early research suggests that the pediatric larynx is too fragile (Von Leden, 1985)

Duration

Voice treatment tends to be recommended more frequently for early or recent nodules

Surgery is more common for established or chronic nodules

(Pannbacker, 1999)

Symptoms

Mild to Moderate Dysphonia Hoarsness* Breathiness Low Pitch Laryngeal Hyperfunction

Children with Asymptomatic Nodules may not Require Treatment

Even with Symptoms, Children may not Perceive the Dysphonia Negatively

(Pannbacker, 1999)

Choice of Treatment

Appears to be influenced by professional discipline In one study by Allen and associates (1991)

Otolaryngologists: Chose voice therapy for children more often than for adults

For both recent and established nodes 81% also felt voice therapy can “always” or “frequently” be

helpful None reported that it was “rarely” or “never” effective

48% felt that “all” or “most” SLPs are adequately trained to deal with the issue

Only 5% “always refer patients to SLPs 81% ”frequently or occasionally refer children for voice

therapy (75% for adults)


Choice of Treatment Cont.

In the same study: 97% of SLPs chose initial voice therapy treatments for both

children and adults However, 27% preferred surgery followed by voice therapy for

established nodules 87% felt voice therapy can “frequently” be effective

However, none felt it was always effective None felt all SLPs were adequately trained

45% felt “most” were 45% felt “some” were

94% “always” or “frequently” refer children with suspected vocal nodules to an ENT (72% of adults)


Choice of Treatment Cont.

In Summary of the study: More SLPs preferred surgery followed by voice Tx for

children with established 26% of SLPs and 5% of physicians

No significant differences were established among the professions in terms of how frequently they felt therapy was effective

SLPs refer children more frequently to ENTs than ENTs refer to SLPs

Both agree that “most” or “some” SLPs are adequately trained to understand vocal nodules


More Studies: TreatmentAdapted from Pannbacker (1999)

Study N

Type of Treatment

Duration of Treatment Measures Findings

Deal, McClain, & Sudderth (1976)

31 children (12 girls, 19 boys)

Reduce talking & laryngeal tension, auditory monitoring

2-3 30-minute sessions per week

Laryngeal appearance

After 2 months of voice Tx 68% reduced nodule size, 23% normal larynges. After 6 months of treatment, 64% reduced nodule size, 65% normal larynges

Kay (1982) 42 children (32 boys, 10 girls)

Voice treatment & surgery

Unspecified Questionnaire, laryngoscopy

Neither voice treatment nor surgery effective

McFarlane & Watterson (1990)

11 children (3 girls, 8 boys), 33 adults (30 women, 3 men)

Vocal hygiene, abuse reduction, vocal retraining

Variable, 5-50 half-hour sessions, average of 20 sessions

Endoscopy & perceptual

Fewer thn 1% had return of nodules. Voice treatment effective in eliminating nodules & returning voice to normal

Pro Voice Therapy

Education is the Key Unless causative factors are eliminated nodules will

recur even after surgery The following techniques have been successful

Vocal Hygiene Vocal Hydration Avoidance of…

Vocal Abuse Vocal Misuse Vocal Overuse (Koufman, n.d.)

Ethically inappropriate to withhold potentially effective treatment

(Pannbacker, 1999)

Some Voice Therapy Procedures

1. Develop Voluntary Vocal Management Skillsa. Reduce amount of talking

b. Reduce vocal loudness

2. Reduce Tension in the Laryngeal Musculature

a. Increase breath flow on phonation

b. Encourage and maintain gentle adduction

3. Develop Auditory Monitoring of Good Voice Production

(Deal, et al., 1976)

Reasons NOT to Recommend Surgical Removal

Tendency to Recur Difficult to modify a child’s vocal behavior

Often remain abusive in the postoperative period

Vocal Nodules often Spontaneously Resolve near Puberty Cheerleaders may be the exception

Even when Vocal Nodules Persist, It is possible to improve voice quality with voice therapy (Koufman, n.d.)

Possibility of Scar Tissue and/or Anesthetic Complications

(Pannbacker,

1999)

No Treatment

Tendency to resolve spontaneously without treatment Therefore, Treatment is unnecessary

Some Children may not be compliant The child might not be aware of the

dysphonia The child might be asymptomatic

(Pannbacker, 1999)

Future Research

There is a need for studies reporting on: effects of voice therapy and surgery on vocal nodules (more) Specific length of time nodules were present, time since

onset of dysphonia, severity of dysphonia, and patient compliance

Length and duration of treatment Distinct types of treatment longitudinal data about spontaneous remission of vocal

nodules outcome measures including both voice and laryngeal

measures as well as functional status Specific criteria for selecting surgical versus nonsurgical

treatment measures

(Pannbacker, 1999)

Summary

There is limited data on the outcome of voice treatment for children with vocal nodules

The majority of studies about vocal nodules have been of adults Only 4 studies included children

Both the number and quality of research studies needs to increase in order to accurately state that voice treatment is efficacious

However, voice treatment is currently the most favored method for treating children If chosen, surgery is often the last option

(Pannbacker, 1999)

References

Allen, M.S., Pettit, J.M., & Sherblom, J.C. (1991). Management of vocal nodules: A regional survey of otolaryngologists and speech-language pathologists. American Speech-Language-Hearing Association, 34(2), 229-235.

American Academy of Otolaryngology, Head and Neck Surgery. (n.d.). Hoarseness in children is often misdiagnosed, leading to ineffective treatment. Retrieved April 2, 2003, from http://entnet.org/ent-press/ pressreleases /ABEA1.cfm

Bowen, C. (1997). Vocal nodules and voice strain. Retrieved April 3, 2003, from http://members.tripod.com/Caroline_Bowen/teen-nodules.htm

Deal, R.D., McClain, B., & Sudderth, J.F. (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.

Koufman, J.A. (n.d.). Vocal Nodules. Retrieved April, 2, 2003, from http://www.bgsm.edu /voice/ocal-nodules.html

Pannbacker, M. (1999). Treatment of vocal nodules: Options and Outcomes. American Journal of Speech-Language Pathology, 8(3), 209-217.

Von Leden, H. (1985). Vocal nodules in children. Ear, Nose, and Throat Journal, (64), 473- 480.