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Vocal Nodules in Children: Treatment and ApproachVocal nodules are the most common type of voice disorder that can occur in human beings. They tend to grow on the place where the maximum amplitude of vibration occurs on the vocal folds. Vocal nodules swell and get bigger depending on their size and can cause the vocal folds to be unable to close completely, resulting in the hoarse, breathiness voice which the child produces. Vocal abuse and outside irritants are the most common reasons why vocal nodules occur (Andrews, 1995).
by Lauren Gans
There are several determiners of whether or not a child is susceptible to developing vocal nodules. According to Andrews, 1995, these include: hoarseness, harshness, periodic aphonia, improved quality when loudness is increased, inefficient inhalation patterns, short duration of exhalation phase, inefficient use of replenishing breaths, throat clearing, hard glottal attacks, observable tension, abusive vocal practices, dryness of the vocal tract, vocal misuse, and vocal vibration limited to loudness increases (p. 164).
It has been proven that vocal nodules frequent more in school-age boys then in school-age girls (Andrews, 1995). This is thought to be due to their abundance of energy and their need to have attention in a social setting, such as when they are playing on the playground.
Vocal nodule severity in children can range from mild to severe. However, all cases can be treated by a Speech Language Pathologist (SLP), and sometimes other professionals, such as an ENT that specializes in this field.
There are many approaches an SLP can take when it comes to voice intervention and therapy. An SLP has to look at the perceptual and acoustic aspects of how the vocal folds are functioning, as well as using a stroboscope for further assessment (Allegro, 2008). When conducting an overall voice evaluation, an SLP has to look at medical history, behavior, social and psychological factors, the child's communication skills and the amount of involvement that the family has in the treatment process. An SLP will have additional training if he/she is involved with treating dysphonia, which can involve variations in the quality, pitch and/or volume of the child's voice (Allegro, 2008).
Treatment can take place in classroom settings, voice clinics, both private and public, hospitals and schools. Therapy can be individual or in groups depending on the needs of the child and the severity of the child's vocal nodules. The severity of the nodules will determine the length of the treatment (Allegro, 2008).
There are many programs designed for pediatric voice disorders. In order for the child to get the most out of the treatment program, clinicians must realize that they need to take extra time to teach the children about their problem and how to overcome it. Materials and activities for voice therapy must be age appropriate and interesting and exciting for the child. The activities planned should be play-based, in order to keep the children's attention.
The first approach that is commonly used to treat vocal nodules in children is direct therapy. Direct therapy incorporates a number of ideas. One technique used by an SLP is to be sure that the child's laryngeal mechanism and voice production are working in unison, improve breathing techniques and to be sure the right amount of loudness, pitch and quality are being used without straining the vocal folds (Allegro, 2008). Explicit techniques such as electromyographic (EMG) bio-feedback can help decrease vocal nodules in children. This approach alleviates jaw tightness and uses instrumentation to illustrate to the child the point at which his or her muscles are tight and should be relaxed. Other approaches such as decreasing how much the child coughs, laryngeal massage and decreasing vocal intensity are all specific techniques that can help children improve the quality of their voices. Also, yawn-sighs, which is described as when one yawns, the pharynx is opened and then when the child takes a big sigh, the larynx lowers (Ranig & Verdolini, 1998) is yet another approach that SLPs utilize while using direct therapy.
Rubin and Lehrhoff (1962) found that direct voice therapy is effective in treating children with vocal nodules. The most effective method of breathing is a blend of costal and diaphragmatic breathing. This is when the child must be taught how to inflate her chest cavity while inhaling and then be able to correctly monitor her exhalations (Rubin & Lehroff, 1962). Children with vocal nodules may lack this sense of breathing and therefore, strain their voices. Children are taught to improve their breathing technique to maximize airflow thru the lungs, improving phonation of the voice. Techniques such as taking a deep breath and letting it out with a prolonged hissing sound can help improve the child's breathing. The more times a child does these exercises, the more the child will benefit from treatment. In addition, breathing softly and holding it for a short period of time and releasing, can help the child. Also, opening the mouth more while speaking is a good exercise for children to use as it gives their lungs more air, causing them to strain their voice less.
Pitch is important when producing speech. Usually children with vocal nodules misuse their pitch production. Therefore, the child's pitch tends to be higher than what is considered to be healthy and appropriate. An SLP works with the child to try to lower his pitch. Techniques that can be used are listening to a recording of someone speaking and imitate what is said, only in a lower pitch. Also, singing down the musical scale as much as the child can without putting tension on their vocal folds may help.
Vocal rest is the most effective way of treating a child with severe nodules. This complete vocal rest prohibits a child from speaking and forces the use of a pen and paper for all means of communication until the clinician feels it is appropriate for the child to speak again. This is a gradual process as once the child starts speaking, it may take a long while for him to speak to his maximum potential. However, this approach may be unrealistic, as it is extremely difficult for a child to not communicate without talking, especially if the child is too young to write out what he or she wants to convey on paper.
Furthermore, it is then the SLPs responsibility to teach the child to whisper in a way that is not detrimental to their vocal folds. The way a clinician teaches the child to communicate is to whisper by way of movement of the lips so that there is no vocal fold movement. Although this is an unrealistic approach for children to become accustomed too, it is a more efficient way of dealing with severe vocal nodules then for a child to be speaking in any situation they come across, whether it be on a playground or sitting at the table eating dinner. If neither of these strategies work, then decreasing the overall level of loudness and avoiding situations that could cause vocal abuse should be tried.
Another approach that is common for SLPs to take on is indirect therapy. This technique is when clinicians educate the child about normal voice production and the disorder of voice production and how to take care of his voice. According to Glaze (1996), family involvement is critical in a child's success in treatment as they are essential for motivating their child to go through with treatment and do the things recommended by the clinician. The family's involvement, whether it be parents, siblings and/or aunts and uncles can all help facilitate the ongoing treatment of a child with vocal nodules. The constant reminders, support and confirmation that the family gives to the child, will only serve in helping the child be more efficient in achieving therapy goals. Handouts are also a good technique used to incorporate parents with treatment. Handouts can consist of different techniques that can be done at home, things to look out for that could harm the child's treatment progress, and what to do if family members see these things happening.
There are many common treatment components that benefit a child with vocal nodules. According to Hooper (2004), these include: "parent/family involvement, teacher involvement in the school-age child, a component of child/family lifestyle education or vocal hygiene education, psychodynamic and interpersonal factors and related behavioral intervention or discussion, the incorporation of vocal behavior into good language and communication behavior, and the use of age-appropriate activities" (p. 324).
Regardless of the therapy approach, clinicians agree that every method must entail “the mastery of a basic voice training gesture; daily and frequent practice to facilitate a new motor pattern; and a gradual progression to increasingly complex tasks within a voice-task hierarchy” (Allegro, 2008, p. 154). As long as these three imperative strategies are put into use during therapy, children will become more successful in reaching their goal.
Surgery is another approach to take if neither direct therapy, indirect therapy and/or resonant therapy do not work. Although surgery may be the easiest and quickest way of treatment, it may not fully resolve the problem of vocal nodules in children (Ferrand, 2008). Ferrand (2008) believes that due to the child's young age and their developing vocal folds, vocal nodules can reappear at any time and is more likely to happen in children. Also, since it is harder for children to learn how to take care of their voice, their detrimental habits could still be intact and the nodules could potentially regrow.
Most clinicians agree with this theory and are therefore more likely to avoid surgery at all cost. If however, treatment is not going well for either the client or the clinician, the SLP will then make a professional decision of whether or not the client needs to work with another SLP or if they need to go see an Otolaryngologist for further treatment.
A study conducted by Moran and Pentz (1987) was done to see the opinions of Otolaryngologists across the United States in whether or not they thought if voice treatment or surgery was a more effective way of treatment for children with vocal nodules. An overall consensus of the Otolaryngologists was that voice treatment was the most effective way of treatment for children with vocal nodules.
Vocal nodules can be treated and prevented if taking the correct and effective approach. Each child with vocal nodules is different and has a distinctive severity of the voice disorder. It is up to the SLP and sometimes, other professionals involved to make an expert decision about what type of therapy approach to take. The therapy then needs to be modified, so the therapy is age appropriate and fits the child's goals.
Out of the treatment approaches discussed in this article, direct therapy, indirect therapy, and surgery, there is not one single approach that is always effective for every child that needs to get treatment. Since each child is different, different tactics are used and some treatment approaches may be used in unison to help the child overcome this unpleasant voice disorder. With underlying support, vocal nodules can be treated and prevented from reappearing in a child with this disease.Lauren Gans is a senior at Hofstra University,NY, majoring in Speech-Language and Hearing Sciences and is pursuing a masters degree in the same area.
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