1. Childhood Vocal Nodules: Concerns and Management By: Julie Phillips

2. 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)

3. 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)

4. 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 2 nd 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)

5. 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)

6. 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 treatment 2. Surgical Removal 3. Voice treatment and surgical removal 4. No Treatment (Allen et al., 1991)

7. 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.)

8. 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

9. 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)

10. 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)

11. 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)

12. 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)

13. 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)

14. 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)

15. More Studies: Treatment Adapted from Pannbacker (1999) StudyN Type of Treatment Duration of Treatment MeasuresFindings 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 UnspecifiedQuestionnaire, 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

16. 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)

17. Some Voice Therapy Procedures 1. Develop Voluntary Vocal Management Skills a. 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)

18. 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)

19. 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 )

20. 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)

21. 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)

22. 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.