1. Pediatric and Geriatric Voice (Colton et al
Pediatric and Geriatric Voice (Colton et al., 2011; hartnick & boseley, 2010
CD 661
1. Lecture 15 Pediatric and Geriatric Voice

2. Laryngeal and VT Anatomy in Children
The infant vocal tract: *Shorter VT: lengthens by 4-6 months *Velum & epiglottis in close proximity til 4-6 mos *VFs: no vocal ligament, undifferentiated LP, thick cover, w/ more vascularity *Arytenoids are disproportionately large until 4-6 months *Laryngeal position is C2- C4; descends to C5 by 2 yrs; C6-C7 by age 15 (Hirano et al., 1983) *Hyoid bone and thyroid cartilage are contiguous til age 2 – enables infant to transition rapidly from swallowing to breathing as needed
2. Laryngeal anatomy in infants and children is quite different from that of adults. The vocal tract is shorter; the velum and epiglottis are in close proximity; the vocal folds lack a ligament and layered structure; the arytenoids are disproportionately large compared to the thyroid and cricoid cartilages; the larynx is high in the neck at C2-C4 and the hyoid bone and thyroid cartilage are contiguous.

3. Laryngeal and VT Anatomy in Children
Lamina propria is 1 layer at birth; evidence of development of 3 layers begins at puberty and is complete by age (Hirano et al., 1983; Ishii et al., 2000)
Vocal ligament may appear by age 4 but continues development thru puberty
Thick VF cover and increased vascularity makes pediatric VF cover more susceptible to inflammatory and post-traumatic edema.
Undifferentiated, thicker cover (LP) affects child’s ability to make fine adjustments needed for register control and create mucosal wave.
3. Infants and children lack a layered VF structure. At birth, the lamina propria is not differentiated into 3 layers and there is no vocal ligament. The vocal fold cover is thick and highly vascular. This all results in the child VF being more susceptible to injuries and inflammation and affect the child’s ability to control vocal registers and mode of phonation. The three layer lamina propria develops gradually, beginning development at puberty and finishing at age By 4 yrs old the vocal ligament is beginning to appear.

4. Laryngeal Neuromuscular Control
Young children: more type II muscle fibers (fast acting but fast fatiguing)
Puberty: more type I muscle fibers (slow contracting, fatigue resistant)
TA muscle continues to develop at least til age 3
SLN and RLN nerve fibers in crease in number, myelination and axonal & dendritic endings til age 3
4. Neuromuscular control is also different in children. Young children have more fast twitch, i.e. fast acting, type II muscle fibers. By puberty, the laryngeal muscles show more slow twitch, or type II, slow acting, fatigue resistant muscle fibers.

5. Pediatric Voice
Differences in pediatric laryngeal anatomy and physiology from adult laryngeal anatomy and physiology result in
differences in pediatric acoustic, aerodynamic and perceptual parameters !
5. It should seem logical that the differences in pediatric laryngeal anatomy and physiology from that of the adult will result in different habitual pitch, different acoustic characteristics etc.

6. Norms for Children Norms – sparse at best
Leeper (1992) and Campisi et al. (2002) – found increased jitter in children w/ nodules versus children w/o
Boltezan et al. (1997) found increased phonatory instability (jitter and shimmer) in all children, w/ male values > female values
ALSO Boltezan found the no one acoustic parameter discerned pathological from non-pathological voices
6. Acoustic and aerodynamic norms for children are sparse at best. Because children have a thicker cover and poorly differentiated lamina propria layers (or lack of layers), children show more frequency and intensity perturbations (i.e. jitter and shimmer) than adults. While some researchers have identified differences in acoustic parameters between children with and without nodules, other studies have found no differences.

7. Acoustic & Aerodynamic Characteristics
Fundamental frequency – high at infancy, 500 Hz, but slowly lowers as child gets older.
Ps is % > for children than for adults and children have lower mean airflow rates
Max phonation times are lower until puberty
Lung volume is less , rib cage excursion greater and rib use vs abdominal use for breathing is > when compared to adults
7. See the table from Hartnick and Boseley for Fo by age. Subglottal pressure is 50%-100% greater for children that for adults. Children have lower mean airflow rates as well. Lung volume is, of course less and rib excursion (expansion) when inhaling is also greater. Children show more ribcage expansion than abdominal wall movement on inhalation.

8. Acoustics (Campisi et al. 2002)
Jitter % norm = 1.4, s.d. = 0.07
RAP norm = s.d. = 0.04
Shimmer % norm = s.d. = 0.12
NHR norm = s.d. = 0.002
Max. Phonation time (Finnegan, 1984)
3-5 yrs old seconds
6-9 yr old seconds
10-12 yrs old seconds
8. Here are some acoustic and maximum phonation time norms for children.

9. Evaluating Voice in Children
Multidisciplinary Team:
I.D. voice problem: Parents, SLP, school nurse or teacher
Referral to Pediatrician
Referral to ENT for voice dx & medical tx or voice tx or both
Referral to SLP for voice evaluation
SLP- therapy, if appropriate
Specialists: allergist, gastroenterologist, pulmonologists etc.
9. Assessment and treatment of a voice pediatric disorder involves a multidisciplinary team. Parents, the teacher, SLP or school nurse may be the first to i.d. the problem. The first physician to see the child may be the pediatrician who then would likely refer the child for an ENT exam. After medical dx by the ENT, the child would either receive medical treatment, voice therapy or both depending on the nature of the disorder. If voice therapy is recommended, the child would receive a voice evaluation form the vice therapist and then subsequent voice therapy. If allergy, reflux or respiratory disease is suspected then appropriate referrals should be made.

10. Evaluating Voice in Children
The ENT Exam –
Nasendoscopy or oral endoscopy w/ or w/o stroboscopy
Child size scopes
Nasendoscope w/ distal chip camera gives greater detail and can be used w/ or w/o strobe
10. Pediatric ENTs use smaller diameter nasendoscopes and oral scopes. Pediatric ENTs are usually very good with children. I kno of a pediatric ENT who will say to the child “stick your little finger in your nostril, does that hurt ? No ? Okay, look at this scope. Which is bigger, your finger or the scope ? Your finger right ? So this scope is smaller than your finger ….etc” Referral to a pediatric ENT, if possible, is the best way to go.

11. The Voice Evaluation (SLP)
Case hx
Perceptual – very important
Oral mech exam
Breathing assessment
Muscle tension assessment
Habitual pitch and intensity measurements
Max Phonation Time
Acoustic and aerodynamic if possible
Stimulability for improved vocal quality
11. Voice evaluation by the SLP involves obtaining a thorough case history, a perceptual evaluation of voice quality, an oral mech exam, breathing assessment, laryngeal muscle tension assessment, determination of habitual pitch and intensity, max. phonation time, acoustic and aerodynamic assessment if possible and stimulability for improved vocal quality.

12. Case History
Onset, possible cause, changes since onset, when is voice worse/better, past problems, types of voice use ?
Parent questionnaires – Voice Surveys
Medical hx – GERD, Allergies, Bronchitis, Asthma, Sinus, Cleft palate, ADD/ADDHD, medications, surgeries etc.
Vocal hygiene - How does child use voice ? I.D. abuse/misuse
Hx of Speech/Language disorders – 40% w/voice disorders also have S/L disorder
12. Case hx information questions include many of the same questions we’d ask an adult. We’ll also administer parent questionnaires regarding the child’s voice problem and level of vocal handicap. A medical hx and medication list is also important. Vocal hygiene assessment to identify vocal abuse/misuse behaviors and exacerbating behaviors is important. Obtaining information regarding the child’s speech and language development is also important. Research shows that 40% of children w /a voice disorder also have a speech or language disorder.

13. Breathing and Muscle Tension
Normal for children to take more frequent breaths w/ greater rib cage excursion than an adult
Abnormal : clavicular breathing, shallow or inadequate replenishment, strap muscle activity during inhalation
Assess breathing at rest and during speech
Palpate larynx and observe at rest and during speech :
Tension in FOM muscles & BOT
Extrinsic laryngeal muscle tension
Laryngeal height
Ability to lateralize larynx
13. Assessment of breathing is the same as for an adult. That said, remember that children will show greater rib cage excursion than abdominal wall excursion compared to an adult. Laryngeal palpation is also the same for a child as for an adult.

14. Congenital Disorders
Laryngomalacia – Soft laryngeal cartilages . May collapse into airway on inhalation. Resolves with maturation.
Most common cause of infant inspiratory stridor
10-20% require surgical intervention (pg. 244)
Endoscopic signs:
collapse of laryngeal cartilages in inspiration
enlarged/floppy arytenoid cartilages
excessive AC mucosa
14. Laryngomalacia is a congenital disorder of unknown etiology and is the most common cause of infant inspiratory stridor. It results in very soft laryngeal cartilages that collapse into the airway on inhalation. It usually resolves with maturation but 10-20% of cases require surgical intervention.

15. Congenital Disorders
Laryngeal Cleft - may be related to an autosomal dominant pattern of inheritance
Cleft on posterior portion of cricoid cartilage causes narrowing of airway.
Symptoms and problems:
Inspiratory & expiratory stridor
Dyspnea
Aspiration
Feeding difficulties
Managed surgically
15. Laryngeal cleft is an extremely rare disorder occurring in 1 out of 20,000 births and is more common in boys than girls. It is diagnosed via microlaryngoscopy and managed surgically. Benjamin and Inglis (1989), presented a classification system in which 4 types of clefts can be described. Types 3 and 4 are most severe. This classification system is outlined nicely in your text on pages

16. Congenital Disorders
Subglottic Stenosis - can be congenital or acquired (trauma/disease)
Is any narrowing of the tissue below the level of the glottis
Third most common congenital condition
Symptoms:
Inspiratory and expiratory stridor, dyspnea, low pitch cough, nostril flaring, excessive chest wall movement
Managed surgically
16. Congenital subglottic stenosis is associated w/ a malformed cricoid cartilage (CC) that occurs in utero and causes the CC to be smaller than normal with a thicker underlying mucosal layer. Acquired subglottic stenosis is usually due to prolonged intubation. Symptoms include inspiratory and expiratory stridor, low pitch cough, dyspnea and significant nostril flaring and chest wall movement indicative of effortful ventilation. Myer et al. (1994) developed a grading system for degree of stenosis which is included in your text reading assignment on page Subglottic stenosis is managed surgically. Advances in the treatment of upper airway disorders have greatly improved surgical outcomes in the management of these disorders resulting in decannulation (removal of trach tube) in 85-90% of patients.

17. Congenital Anomalies
Laryngeal Paralysis – due to birth trauma or CNS damage, Arnold Chiari malformation
Laryngeal Web – due to chromosomal abnormality
Congenital Cyst – rare
VF papilloma
17. Laryngeal paralysis, laryngeal web, congenital VF cyst and VF papilloma are also congenital laryngeal disorders.

18. Signs of congenital anomalies
Stridor
Dysphonia
Difficulty breathing
Abnormal cry
Coughing, choking
18. Signs of laryngomalacia, subglottal stenosis, laryngeal web and VF papilloma include stridor, dysphonia, difficulty breathing, abnormal cry and coughing or choking.

19. Acquired Disorders
VF nodules – most common acquired voice disorder in children
Accounts for 50% of acquired pediatric voice disorders
VF Paralysis – trauma to RLN
Laryngopharyngeal Reflux
19. The most common acquired pediatric voice disorder is VF nodules. It accounts for 50% of acquired voice disorders.

20. Tx of Nodules in Children
Conservative approach is BEST – no surgery
Involve family, teacher
I.D. and modify causal behaviors
Minimize excessive inappropriate vocal behaviors
Trend – adults who had nodules as children seem to have a higher incidence of voice problems
Resonant Voice Therapy and Flow Phonation
Breathing exs. and /or muscle relaxation exs.
20. Recall that VF nodules are due to phonotrauma, typically excessive loud talking, yelling, screaming etc. Thus inappropriate vocal behaviors must be i.d.’d and decreased. The standard of care for VF nodules is therapy first. The parents must be involved for treatment to be successful because vocal behaviors must be monitored at home. If the family communication style involves yelling from room to room and talking loudly over one another, the family may need to modify their vocal habits as well. Therapy may consist of muscle relaxation exercises if muscle tension is present, breathing exercises if clavicular breathing is present or child speaks too long on one breath, Resonant Voice Therapy and Flow Phonation. Dr. Verdolini has developed a wonderful voice therapy protocol for children called ‘Adventures in Voice’ that includes Resonant Voice techniques and also teaches children to be loud safely.

21. Importance of Pediatric Referrals
Persistent hoarseness, raspiness, breathiness, strain etc. are not normal
Hoarseness can be due to many things, including papilloma or nodules
Breathiness can be due to VF paralysis
Referral to an ENT is important
21. The importance of pediatric voice referrals cannot be underestimated. Pediatric voice disorders can affect a child’s participation in class, result in teasing, and less social engagement and are covered for remediation under IDEA.

22. Geriatric Voice VF characteristics in persons > 65 y/o –
* laryngeal cartilages calcify
* blood flow to structures decreases
* lamina propria thickens: less elastin and collagen, more fibrotic tissue
* atrophy of sub mucous glands
* atrophy of muscles
* decreased neuronal firing rates for TA and CT
22. As people age many anatomical and physiological changes occur. Changes to the larynx and vocal folds occur as well. The laryngeal cartilages calcify, blood flow decreases, the lamina propria thickens, the sub mucous glands and muscles atrophy. All of these changes can affect vocal quality.

23. Geriatric Voice Perceptual – may vary w/ gender
habitual pitch higher in males, lower in females
hoarseness
breathiness
decreased frequency & intensity ranges
Acoustics:
Greater Fo variability, increased jitter, decreased intensity variability, slower speaking rate
23. Research is some what conflicting regarding changes in Fo by gender. While some studies show increased Fo for men and decreased Fo for women, other studies show that Fo remains relatively the same for women but increases for men. Studies examining acoustic characteristics of the geriatric voice generally found increased jitter, greater Fo variability, decreased intensity variability.

24. Geriatric Voice Aerodynamics –
*smaller vital capacity (decr in lung volume)
*decreased lung pressure
*greater peak airflow and greater air leakage
*greater open quotient
decreased MFDR
24. As we age, our vital capacity decreases, lung pressure decreases and there is greater peak airflow and air leakage and open quotient increases. Increased peak airflow, leakage and open quotient are likely due to incomplete glottal closure.

25. Geriatric Voice Laryngoscopic
* bowing, incomplete closure, posterior gap
* vocal process prominence
* atrophy & thinning of VFs
* edema
* decr mucosal wave & amplitude of vibration
* incr VF stiffness
* increased aperiodicity
25. Studies examining laryngoscopic characteristics of the elderly voice show some type of glottic incompetency such as bowing, incomplete closure and posterior glottic gap. The vocal processes become more prominent and the VFs may appear thin or edemic. There may also be decreased mucosal wave due to increased VF stiffness.

26. Geriatric Voice
Many voice problems in the elderly are NOT caused by aging (4%) but by disease
Disorders vary but most common are :
Laryngeal cancer (men)
VF paralysis
Edema
Nodules & polyps (> in women)
(Herrington-Hall et al, 1988)
26. Most geriatric voice problems are not due to presbylaryngis, but to disease. Geriatric patients should be seen when there is a change in vocal quality to rule out voice disorders unrelated to age related laryngeal anatomical and physiological changes.