Information for Families: Vocal Nodules in Children

 


Ear Nose and Throat Specialist


Speech-Language Pathologists / Speech and Language Therapists (SLPs/SLTs) do not treat vocal nodules or hoarse voices in children or adults until the person's larynx (voice box) has been examined by an Ear Nose & Throat (ENT) specialist. It is the ENT specialist's task to determine the medical reason, if any, that a person has voice symptoms such as hoarseness or frequent loss of voice. This examination is called laryngoscopy.

Laryngoscopy usually occurs in the ENT specialist's consulting room. Sometimes it is done under general anaesthetic.

The ENT specialist may find a problem that requires a surgical or medical solution (i.e., not speech pathology treatment). On the other hand, they may find a problem that is best treated by a SLP/SLT. Alternatively, surgery and voice therapy may be required.

If necessary, having performed the laryngoscopy, the ENT specialist informs the SLP/SLT of what he or she observed, and diagnosed, in the patient's larynx (e.g., normal structure and function, reddened vocal cords, laryngitis, vocal nodules, a paralysed vocal cord, bowing of the cords, vocal polyps, granuloma, etc). From this information the SLP/SLT can determine the appropriate course of speech pathology intervention (treatment).


Speech Therapy Management of Voice Issues


The following notes notes relate to the SLP/SLT management of children with nodules or voice strain.

Detailed case history

Once the child has had an ENT examination, speech-language pathology assessment can commence. As part of the initial process, the speech-language pathologist needs to take a very detailed case history, which can involve asking parent/s some very searching and personal questions. These questions cover areas such as the child's early development, the way they get on with other people, relationships within the family including the way family disputes are resolved, behaviour management, peer relationships, health history including allergies, and the child's personality.

Treatment

The overall aim of voice therapy is to teach a healthy, non-abusive voice production pattern. The speech-language pathology treatment of nodules and vocal strain in children begins by educating the child and his or her family about the nature of the problem, including its signs and symptoms, causes and risk factors.

It is helpful for the child and family to understand the normal anatomy and physiology of the larynx (“voice box”), in relation to the child’s specific laryngeal pathology (e.g., nodules, thickened vocal cords, etc).

The potentially damaging effects of tension and strain upon the larynx due to forcing the voice need to be explained to the child and his or her family.

The child is taught about voice production: phonation (how the sound is produced by the vocal cords); respiration (breathing); and, resonance.

The idea of adequate breathing patterns are explained, and the child is helped to “feel” the sensations of appropriate breath support sitting, standing and lying down.

They are shown how to check that the level of the thyroid notch does not rise excessively during gentle humming (e.g., “hmmm, ummm, hummm...”).

They also learn to palpate (feel) their own necks, or to look in a mirror, for excessive neck muscle tension around the larynx.

Finally, the child learns, by imitating the therapist, how to produce resonance in different parts of the vocal tract: e.g., “chest” voice, “head” voice, and “nasal” voice, and front and back oral resonance.

This voice training provides a foundation for learning to produce the best voice with the least effort.

Resonance training is especially important, since it helps if children with abusive voice production habits can be taught to “project” their voices to achieve increased loudness, rather than using a loud strained voice.

Throughout therapy children are encouraged to remember that: “If your voice sounds good, you are using it a healthy way”.

The term 'hyperfunctional' means 'overused'. Hyperfunctional voice disorders, and laryngeal pathology such as vocal nodules almost always result from some form of vocal abuse or misuse. It is therefore essential to identify abusive behaviours (hence the need for detailed case history taking at the outset of therapy) and reduce or eliminate them, so that the cords can heal and recover, allowing a return to normal voice.

Simple voice exercises, performed morning and evening, are helpful in many cases in “warming up” and “cooling down” the voice. These exercises are outlined and supervised, according to the particular patient's needs, by the speech-language pathologist.

Reference

Glaze, L.E. (1996). Treatment of voice hyperfunction in the pre-adolescent. Language, Speech & Hearing Services in Schools, 27, 3, 244-250.


Signs and symptoms


The signs and symptoms of childhood nodules or vocal strain include one or more of the following:

  1. dysphonia, which is a hoarse, breathy or rough voice; or a voice with excessive 'glottal fry' (a 'croaky' characteristic that very old voices sometimes have, but which is not normal in young voices)
  2. intermittent aphonia, which is a recurring temporary loss of voice, especially first thing in the morning and at the end of the day, or after specific events such as sports day
  3. voice breaks, which are fleeting interruptions to the voice, during speech or singing, as though it “cuts out” for a second
  4. pitch breaks, which are fleeting, abrupt changes in the pitch of the voice, during speech or singing, usually from a lower note to a higher note
  5. an excessively loud voice, this requires no explanation. Every family has a "built-in" appreciation of how loud is too loud.
  6. an inability to sustain a note when singing, in which the voice wavers or cuts out.
  7. an effortful or strained voice, in which the person sounds as though producing voice requires special effort: their voice-production does not seem to be efficient.

Causes


Voice strain and nodules are caused by stress to the larynx, within which are the delicate vocal cords. This stress is generally referred to as “vocal abuse”.

It is rare to find just one “abusive” behaviour producing voice symptoms.

Classically, children with nodules are in the habit of talking too long, too loudly and with too much effort.

Usually children develop vocal nodules or vocal strain due to the interaction of two or more of the following, done to excess:

  1. talking and singing, for example: excessive and over-enthusiastic rehearsal of school plays or concerts; excessive choir or solo-singing practice; overusing the voice on school camps or excursions; shouting in the playground; talking and shouting against background noise, such as in a swimming pool; overusing the voice during an infection such as a head cold; cheer leading; and overusing the voice when tired or emotionally upset. Lengthy talking, even at normal rate and volume, but without a quiet “recovery time” can also contribute to vocal strain and nodule formation.
  2. glottal attack, sharp glottal attack and forceful use of the voice can seriously damage the vocal cords.
  3. coughing, and loud, forceful sneezing: many children with nodules do not rest their voices when they have upper respiratory tract infections, even when their throats are sore. Coughing and sneezing can be particularly problematic for a child with asthma or a post nasal drip.
  4. crying, laughing and loud or prolonged outbursts of emotion: for example, even very young children who tantrum frequently can develop nodules. Inappropriate or unresolved coping mechanisms for negative emotions (anger, fear, sadness, nervousness) can lead to bottled up anger, explosive outbursts or irrational behaviour, accompanied by loud, forceful voice use.
  5. shouting, cheering and screaming: one loud episode at a sporting event or pop concert is sufficient to produce an episode of aphonia.
  6. grunting : grunting while load-bearing, for example in a rugby scrum or while weight training, puts a sudden shock through the vocal cords as they “fix” into position to create a vacuum in order to “take the weight”.
  7. throat clearing: the chronic throat clearing associated with post nasal drip puts a constant strain on the vocal cords, which are g-r-o-u-n-d together each time the throat is cleared.
  8. making sound-effects: Dalek, explosion and monster noises, especially if they are made while breathing IN (!) put a tremendous strain on the cords, as can assuming character accents, for example Power Rangers, Rambo, Street Sharks, and macho villain and “tough guy” impersonations, and using excessive and deliberate glottal fry when speaking.
  9. dryness: the overuse of certain medications, such as cough lozenges, antihistamines and patent “cold cures”, especially in conjunction with voice overuse, infections or allergy dries out the delicate lining of the larynx and vocal cords, making voice symptoms worse. Caffeine (e.g., in cola) can act as a diuretic, adding to drying effects. Mouth breathing is also potentially drying.
  10. restricted fluid intake: for a healthy respiratory and vocal system good hydration is necessary. A simple way of checking for adequate fluid intake is to ensure that urine is pale in colour.

Risk factors


Some children are more vulnerable to developing vocal nodules and vocal strain than others. Children who are more at risk may have one or more of the following:

  1. a family with loud voice habits such as yelling around the house and calling from room to room in constant background noise. Some children with vocal problems have developed habitually loud voices simply in order to “get the message across” in a constantly loud household.
  2. chronic asthma and/or allergies (including post nasal drip and allergic rhinitis); and incorrect use of some puffers (i.e., no spacer and/or drink of water when they are recommended)
  3. recurrent and frequent upper respiratory tract infections including infected tonsils, sinuses, adenoids and throat
  4. gastric reflux
  5. affective disorders such as attention deficit disorder and hyperactivity, or a “temperamental personality”
  6. behaviour problems
  7. excessive stress or tension in the child’s life, due to internal factors (within the child), external factors (within the environment) or interpersonal factors (e.g., conflict or competition)
  8. a loud, outgoing, enthusiastic, competitive personality with a tendency to “act out” emotionally (their parents can often remember them as terrible “terrible two’s” who tantrumed loud and long and who could whinge endlessly). Some babies just seem to be born loud and lovable, and grow into loud and lovable toddlers and children, some of whom are, unfortunately, 'at risk' for voice problems.