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Signs and symptoms
The signs and symptoms of childhood
nodules or vocal strain include one or more of the following:
- 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)
- 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
- voice breaks, which are fleeting interruptions to the voice,
during speech or singing, as though it “cuts out” for a second
- 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
- an excessively loud voice, this requires no explanation.
Every family has a "built-in" appreciation of how loud is too loud.
- an inability to sustain a note when singing, in which the
voice wavers or cuts out.
- 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.
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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:
- 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.
- glottal attack, sharp glottal attack and forceful use of the
voice can seriously damage the vocal cords.
- 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.
- 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.
- shouting, cheering and screaming: one loud episode at a
sporting event or pop concert is sufficient to produce an episode of aphonia.
- 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”.
- 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.
- 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.
- 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.
- 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.
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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:
- 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.
- 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)
- recurrent and frequent upper respiratory tract infections
including infected tonsils, sinuses, adenoids and throat
- gastric reflux
- affective disorders such as attention deficit disorder and
hyperactivity, or a “temperamental personality”
- behaviour problems
- 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)
- 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.
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