Childhood Vocal Nodules: Concerns and Management By: Julie Phillips.
-
Upload
paul-george -
Category
Documents
-
view
217 -
download
1
Transcript of Childhood Vocal Nodules: Concerns and Management By: Julie Phillips.
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)
(Allen et al., 1991)
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)
(Allen et al., 1991)
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
(Allen et al., 1991)
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.