Voice Disorders and Analysis in Children

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Voice Disorders and Analysis in Children

Pediatric Otolaryngology
Author Credentials 

William O. Collins, MD
Associate Professor
Department of Otolaryngology
University of Florida College of Medicine
Gainesville, FL

Module Summary

Children frequently present with hoarseness or changes in their voice. Prompt recognition of children with more worrisome symptoms is important, as voice disorders may sometimes be an early sign of impending airway compromise. Fortunately, many disorders of the vocal folds in children can be managed non-surgically, including watchful waiting and speech therapy. Surgical treatment is reserved for only specific cases. Therefore, it is important to make the correct diagnosis to match up with the correct treatments.

Module Learning Objectives 
  1. Review normal voice production and physiology, and the pertinent histologic differences in the developing vocal fold histology in children.
  2. Describe common clinical presentations for children with voice disorders and why some may be more common in children.
  3. Describe treatment regimens for voice disorders in children, including both surgical and non-surgical options.

Embryology

Learning Objectives 

To understand the embryologic development of the larynx.

References 
  1. Henick DH, Holinger LD. Laryngeal development. In: Holinger LD, Lusk RP, Green CG, Editors, Pediatric Laryngology and Bronchoesophagology. Philadelphia: Lippincott-Raven; 1997:13.
  2. Boseley ME, Hartnick CJ. Development of the human true vocal fold: depth of cell layers and quantifying cell types within the lamina propria. Ann Otol Rhinol Laryngol. 2006;115(10):784-788.

Anatomy

Learning Objectives 

To describe the structural anatomy of the human larynx.

References 
  1. Hartnick CJ, Rehbar R, Prasad V. Development and maturation of the pediatric human vocal fold lamina propria. Laryngoscope. 2005 Jan;115(1):4-15.
  2. Zeitels SM, Healy GB. Laryngology and phonosurgery. N Engl J Med. 2003;349:882-92.
  3. Boseley ME, Hartnick CJ. Development of the human true vocal fold: depth of cell layers and quantifying cell types within the lamina propria. Ann Otol Rhinol Laryngol. 2006;115(10):784-788.

Pathogenesis

Learning Objectives 

To describe how histologic differences in the mature vs. immature and developing vocal folds affect vocal performance and pathology.

References 
  1. Bulmer DM, Ali MS, Brownlee IA, Dettmar PW, Pearson JP. Laryngeal mucosa: its susceptibility to damage by acid and pepsin. Laryngoscope. 2010 Apr;120(4):777-782.

Basic Science

Learning Objectives 

To describe the histologic structure of the juvenile vocal folds.

References 
  1. Sapienza CM, Ruddy BH, Baker S. Laryngeal structure and function in the pediatric larynx: clinical applications. Lang Speech Hear Serv Sch. 2004 Oct;35(4):299-307.
  2. Boseley ME, Hartnick CJ. Development of the human true vocal fold: depth of cell layers and quantifying cell types within the lamina propria. Ann Otol Rhinol Laryngol. 2006;115(10):784-788.

Incidence

Learning Objectives 

To describe the incidence of common causes of vocal dysfunction in children.

References 
  1. Carding PN, Roulstone S, Northstone K, ALSPAC Study Team. The prevalence of childhood dysphonia: a cross-sectional study. J Voice. 2006 Dec;20(4):623-30.
  2. Shah RK, Woodnorth GH, Glynn A, et al. Pediatric vocal nodules: correlation with perceptual voice analysis. Int J Pediatr Otorhinolaryngol. 2005;69(7):903-909.

Genetics

Learning Objectives 

To describe genetic syndromes with vocal fold manifestations.

References 
  1. Miyamoto RC, Cotton RT, Rope AF, Hopkin RJ, Cohen AP, Shott SR, Rutter MJ. Association of anterior glottic webs with velocardiofacial syndrome (chromosome 22q11.2 deletion). Otolaryngol Head Neck Surg. 2004;130:415-417.

Patient Evaluation

Learning Objectives 

To formulate a strategy for the comprehensive evaluation of a children with vocal disturbance.

References 
  1. Baker S, Kelchner L, Weinrich B, Lee L, Willging P, Cotton R, Zur K. Pediatric laryngotracheal stenosis and airway reconstruction: a review of voice outcomes, assessment, and treatment issues. J Voice. 2006 Dec;20(4):631-41
  2. Boseley ME, Cunningham MJ, Volk MS, Hartnick CJ. Validation of the Pediatric Voice-Related Quality-of-Life survey. Arch Otolaryngol Head Neck Surg. 2006 Jul;132(7):717-20.
  3. Zur KB, Cotton S, Kelchner L, Baker S, Weinrich B, Lee L. Pediatric Voice Handicap Index (pVHI): a new tool for evaluating pediatric dysphonia. Int J Pediatr Otorhinolaryngol. 2007 Jan;71(1):77-82.
  4. Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg. 2009 May;108(5):1475-1479.
  5. Meredith ML, Theis SM, McMurray JS, Zhang Y, Jiang JJ. Describing pediatric dysphonia with nonlinear dynamic parameters. Int J Pediatr Otorhinolaryngol. 2008;72(12):1829-1836.

Measurement of Functional Status

Learning Objectives 

To describe how to perform a vocal analysis in children.

References 
  1. Campisi P, Tewfik TL, Pelland-Blais E, Husein M, Sadeghi N. Multidimensional Voice Program analysis in children with vocal cord nodules. J Otolaryngol. 2000 Oct; 29(5):302-8.
  2. Gartlan MG, Peterson KL, Luschei ES, Hoffman HT, Smith RJ. Bipolar hooked-wire electromyographic technique in the evaluation of pediatric vocal cord paralysis. Ann Otol Rhinol Laryngol. 1993 Sep;102(9):695-700.
  3. Hartnick CJ, Zeitels SM. Pediatric video laryngo-stroboscopy. Internat J Ped Otorhinolaryngol. 2005;69:215-19.
  4. Jacobs IN, Finkel RS. Laryngeal electromyography in the management of vocal cord mobility problems in children. Laryngoscope. 2002 Jul;112(7 Pt 1):1243-8.
  5. Shah RK, Engel SH, Choi SS. Relationship between voice quality and vocal nodule size. Otolaryngol Head Neck Surg. 2008;139:723-726.
  6. Weinrich B, Baker S, Kelchner L, Middendorf J, Krival K, Elluru R, Zur KB. Examination of aerodynamic measures and strain by vibratory source. Otolaryngol Head Neck Surg. 2007 Mar;136(3):455-8.

Treatment

Learning Objectives 

To develop a treatment strategy for children with vocal disorders.

References 
  1. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD). Laryngoscope. 1991;101(Suppl 53):1-78.
  2. Simberg S, Sala E, Tuomainen J, Ronnemaa AM. Vocal symptoms and allergy: a pilot study. J Voice. 2007 Jul 9; (Epub ahead of print).
  3. Thompson DM, Arora AS, Romero Y, Dauer EH. Eosinophilic esophagitis: its role in aerodigestive tract disorders. Otolaryngol Clin North Am. 2006 Feb;39(1):205-21.
  4. Wohl DL. Nonsurgical management of pediatric vocal fold nodules. Arch Otolaryngol Head Neck Surg. 2005 Jan;131(1):68-70.

Medical Therapies

Learning Objectives 

To describe the roles for non-surgical therapies in the treatment of children with vocal fold disorders:

  1. Speech therapy
  2. Adjuvant medical therapy
    1. Anti-reflux therapy
References 
  1. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD). Laryngoscope. 1991;101(Suppl 53):1-78.
  2. Simberg S, Sala E, Tuomainen J, Ronnemaa AM. Vocal symptoms and allergy: a pilot study. J Voice. 2007 Jul 9; (Epub ahead of print).
  3. Thompson DM, Arora AS, Romero Y, Dauer EH. Eosinophilic esophagitis: its role in aerodigestive tract disorders. Otolaryngol Clin North Am. 2006 Feb;39(1):205-21.
  4. Wohl DL. Nonsurgical management of pediatric vocal fold nodules. Arch Otolaryngol Head Neck Surg. 2005 Jan;131(1):68-70.

Surgical Therapies

Learning Objectives 

To describe surgical treatment options for common vocal fold disorders in children.

References 
  1. Hartnick CJ, Boseley ME, Franco RA Jr, Cunningham MJ, Pransky S. Efficacy of treating children with anterior commissure and true vocal fold respiratory papilloma with the 585-nm pulsed-dye laser. Arch Otolaryngol Head Neck Surg. 2007 Feb;133(2):127-30.
  2. Parikh SR. Pediatric unilateral vocal fold immobility. Otolaryngol Clin North Am. 2004 Feb;37(1):203-15.
  3. Patel NJ, Kerschner JE, Merati AL. The use of injectable collagen in the management of pediatric vocal unilateral fold paralysis. Int J Pediatr Otorhinolaryngol. 2003;67(12):1355-60.
  4. Rosen CA, Gartner-Schmidt J, Casiano R, Anderson TD, Johnson F, Reussner L, Remacle M, Sataloff RT, Abitbol J, Shaw G, Archer S, McWhorter A. Vocal fold augmentation with calcium hydroxylapatite (CaHA). Otolaryngol Head Neck Surg. 2007 Feb;136(2):198-204.
  5. Schraff S, Derkay CS, Burke B, Lawson L. American Society of Pediatric Otolaryngology members' experience with recurrent respiratory papillomatosis and the use of adjuvant therapy. Arch Otolaryngol Head Neck Surg. 2004 Sep;130(9):1039-42.

Rehabilitation

Learning Objectives 

To understand the role of speech therapy in the management of children with vocal disorders.

References 
  1. Baker S, Kelchner L, Weinrich B, Lee L, Willging P, Cotton R, Zur K. Pediatric laryngotracheal stenosis and airway reconstruction: a review of voice outcomes, assessment, and treatment issues. J Voice. 2006 Dec;20(4):631-41.
  2. Krival K, Kelchner LN, Weinrich B, Baker SE, Lee L, Middendorf JH, Zur KB. Vibratory source, vocal quality and fundamental frequency following pediatric laryngotracheal reconstruction. Int J Pediatr Otorhinolaryngol. 2007 Aug;71(8):1261-9. 
  3. Lee EK, Son YI. Muscle tension dysphonia in children: voice characteristics and outcome of voice therapy. Int J Pediatr Otorhinolaryngol. 2005 Jul;69(7):911-7.
  4. Shah RK, Woodnorth GH, Glynn A, Nuss RC. Pediatric vocal nodules: correlation with perceptual voice analysis. Int J Pediatr Otorhinolaryngol. 2005 Jul;69(7):903-9.
  5. Trani M, Ghidini A, Bergamini G, Presutti L. Voice therapy in pediatric functional dysphonia: a prospective study. Int J Pediatr Otorhinolaryngol. 2007 Mar;71(3):379-84.

Case Studies

  1. A 7 year old male presents with a history of progressive dysphonia. What factors are important to obtain from the history in this child? What would be the best way to evaluate the larynx in this child?
  2. A 4 year old male has persistent dysphonia following laryngotracheal reconstruction and eventual decannulation. What would be the expected findings on videostroboscopy? What non-surgical interventions could be offered to this child?
Resources 

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