Treatment of Pediatric Voice Disorders

Key Glossary Terms

Stridor
Noisy breathing

Larynx
Highly specialized structure atop the windpipe responsible for sound production, air passage during breathing and protecting the airway during swallowing

Glossary

Hoarseness is typically caused by irritation and swelling of the vocal folds. Successful treatment requires the removal of the irritating condition.

• If irritation is caused by backflow of stomach fluids to the throat and voice box (laryngopharyngeal reflux), the LPR should be treated.
• If irritation is from vocal abuse, tips to avoid abusing the voice are given.
• If irritation is from postnasal drip, interventions to clear the nose are done.
• If irritation is from small growths like papilloma or cysts, they are surgically removed.

Often, however, the exact irritating cause of the hoarseness cannot be identified. If that is the case, a treatment plan is formulated with the consensus of the voice care team (otolaryngologist, speech language pathologist) and the family. (For more information, see Voice Care Team.)

• Speech therapy is generally helpful in all conditions. It can be especially helpful in children who use their voice aggressively or who are required to use a harsh aggressive attack with their voice because of their hoarseness.
• Techniques to encourage a comfortable initiation of voicing are taught to the child. The parents are also taught so that they can help the child practice at home.
• The child must use the techniques outside of the therapy sessions if success is to be achieved. Alternatives to rough play noises are sought. Techniques for translating comfortable voice to comfortable yelling or projecting are also taught to children who play sports or who have to be heard over noise.

• Behavioral modifications include avoiding reclining with a full stomach, eating shortly before sleep, or eating fatty, acidic, or spicy foods.
• Caffeine and nicotine promote relaxation of the lower esophageal sphincter and should be avoided. Many carbonated beverages are loaded with caffeine.
• Depending on the severity of the reflux, the otolaryngologist may prescribe medication to help neutralize the secretions of the stomach. A consultation with a gastroenterologist may also be necessary.

• Cysts in the vocal folds are usually removed, preserving the vibrating portions of the vocal folds while avoiding scarring.
• Papillomas are debulked to alleviate blockage of the breathing passages while avoiding permanent damage to the vocal folds during their removal.
• Occasionally, children continue to have vocal nodules despite mastery of voice therapy and successful treatment of all other causes of vocal fold irritation. These children may benefit from careful removal of the nodular thickening to give them a smooth vocal fold surface. Equalizing the mass and balancing the vibratory character of both vocal folds can make it easier for the initiation and maintenance of voice production. Extreme care must be taken not to disturb the deeper structures of the vocal folds and thus prevent scarring. Children who cannot master good voice use or who continue to have irritation of the vocal folds from other sources like reflux are likely to have recurrence of their vocal nodules. Surgery should be avoided in these children to prevent permanent worsening of the voice.

Nearly every child's voice can improve with treatment. There may be some residual hoarseness or fluctuations in the quality of the voice, but almost all patients improve.

The key is to find the right combination of treatment strategies that maximizes the voice condition at minimal risk. The degree of difficulty to maintain "best voice" should also assessed.

Although rare, there are some situations when a normal voice can be reached through strict voice therapy and rigorous behavior changes at the expense of quality of life. It may be worthwhile accepting the risk of some surgical treatment in these situations to ease the burden required to maintain a decent voice.

Both the family and the voice care team should discuss the expectations and final result desired prior to any treatment. Everyone should agree on the goals and expected treatment outcomes before any treatment is initiated.

Advances in the treatment of voice disorders in children are progressing on multiple fronts.

• New instruments to visualize the larynx in children are being introduced as technology enables the miniaturization of various instruments.
• Voice analysis instruments are also being calibrated for use in children.
• Normative data on growing children is not yet available but is being collected.
• Surgical techniques used in adults are being adjusted for the pediatric larynx.
• Investigators are continuing to learn about the vocal folds and the substances that compose them. The extracellular matrix and the ultrastructure of the pediatric larynx are known to change with age. It is unclear whether this can be used to our advantage or if this makes surgical interventions of the pediatric larynx more hazardous.
• Advances in microlaryngeal surgery techniques continue to improve our ability to safely correct anatomical problems of the pediatric larynx.