Kidmunicate Voice Disorders

Causes, Signs and Symptoms, Diagnosis, Treatment and Prognosis of Voice Disorders

Pediatric voice disorders are common. They are characterized by an abnormal quality of the voice (hoarseness, harshness, nasally and breathiness), the pitch (too high or too low), the volume (too loud or too soft), etc. The most common pediatric voice disorder is hoarseness due to excessive yelling, screaming, crying and talking. Children respond well to treatments that reduce the behaviors (poor vocal hygiene) that cause the issues. Early intervention and treatment of pediatric voice disorders is highly recommended because it can prevent life long voice impairment.

Voice Disorder Causes

The term voice disorder is a broad term that refers to an abnormality in the anatomy and/or physiology of the voice mechanism- which impacts voice quality and breathing. There are a variety of voice disorders and vocal pathologies that may be causing your child’s voice to sound different and breathing pattern to change. There are also a variety of reasons a vocal pathology can occur.

We are going to highlight some of the most prominent causes of voice disorders. If you do not think any of these causes fit your child, or your child has a diagnosis that is not listed and you have concerns about their voice, you should still seek the opinion of a professional such as an Otolaryngologist (ENT), or a speech-language pathologist.

Poor vocal hygiene significantly impacts voice health and can lead to a voice disorder. Vocal hygiene refers to your habits and lifestyle as it relates to the health and support of your voice. Examples of poor vocal hygiene are dehydration, frequent yelling/screaming, frequent throat clearing, frequent whispering, significant caffeine intake, untreated gastroesophageal reflux (GERD) or laryngopharyngeal reflux (LPR), significant and extended voice use without rest, and smoking or secondhand smoke. Poor vocal hygiene or continued improper voice use can cause voice disorders such as vocal fold nodules, vocal fold polyps, Reinke’s Edema, GERD laryngitis, and laryngeal edema. Your voice is a muscle, just like any other in your body. If you try to run a mile without stretching and hydrating, you are at risk of injury. Your voice works the same way, if you try to talk all day without resting, warming up, and without proper hydration, you are at risk of injury.

A unilateral or bilateral paralysis and paresis of the vocal cords can cause the voice to sound abnormal. A paralysis is when the one or both of the vocal cords do not move properly (open or close properly). A paresis is also when one or both of the cords do not move properly, but they may still be able to move slightly. Overall, both of these disorders impair the vibration of your vocal cords. Your vocal cords are a symmetric pair. When one side does not work as it is supposed to, it prevents the vocal cords from vibrating the way they are supposed to. Potential causes of paresis or paralysis are trauma to the head or neck, head/neck surgery, tumors at the skull base, strokes, and postviral vagal neuropathy. A speech-language pathologist and ENT will work together to determine the best way to improve your child’s voice and potentially swallowing if they are diagnosed with paralysis or paresis of the vocal cord(s).

Paradoxical Vocal Fold Motion Disorder (PVFMD) is when the motion of the vocal cords is abnormal, causing the vocal folds/cords to close when they are supposed to open during the breath cycle. PVFMD is often misdiagnosed as asthma because when the vocal cords shut during breathing, it mimics the feeling of an asthma attack. Each case is different, but some potential contributors to PVFMD are acid reflux, stress and anxiety, and lung conditions.

If you have any other questions or concerns about what may be causing your child’s voice quality to change, reach out to an Otolaryngologist (ENT) or feel free to give us a call at Kidmunicate and we will connect you with one of our educated therapists.

Voice Disorder Signs and Symptoms

As with many speech and language disorders, different voice disorders share symptoms and can share symptoms with other conditions. A team of skilled professionals will work to determine what is causing your child’s voice difficulty. The main sign/symptoms of a voice disorder would be as follows:

  • A sudden change in voice quality (sudden breathiness, hoarseness, etc.)
  • A hoarse voice due to a cold/illness that persists past recovery
  • Consistent pain or coughing with voicing
  • Asthma inhalers are not helping breathing difficulty
  • Difficulty onsetting sound- you go to talk and you cannot make a sound
  • Poor overall voice quality- hoarse, breathy, strained voice
  • Stridor- noisy breathing, voicing on the inhale

If you feel like your child may match some of these criteria, your first step should be to see an ENT. They determine if speech therapy is warranted.

Voice Disorder Diagnosis

If a voice disorder is suspected, it is imperative that your child receive a full evaluation by a qualified Otolaryngologist or an ENT. They will determine if there is a vocal pathology and take the necessary steps to diagnose. Speech therapists must receive a referral or prescription from an ENT for voice therapy to be conducted. If you would like a screening by a skilled speech-language pathologist to determine if an ENT visit is warranted, please call to schedule.

A speech-language pathologist could give you more information on or provide therapy for the following diagnoses: vocal fold nodules, cysts, and polyps, vocal fold paresis and paralysis, vocal fold hemorrhage, laryngitis, gastroesophageal reflux laryngitis, Reinke’s Edema, spasmodic dysphonia, vocal fold granuloma, vocal fold scarring, laryngeal dystonia, aphonia, post viral vagal neuropathy, mutational falsetto, and paradoxical vocal fold movement disorder (PVFMD). If you have questions about a disorder not listed, please still call us and we will connect you with a skilled professional.

If speech therapy is warranted it is important to bring all necessary paperwork, including, but not limited to: the ENT evaluation report, stroboscopy video, current medication list, prescription/referral for therapy, and past medical history information. At Kidmunicate, our speech-language pathologist will assess the following:

  • Reflux Symptoms. Your child’s oral anatomy will be examined and his ENT evaluation will be referenced to determine if there are any signs or symptoms of reflux. You or your child will be asked pertinent questions to determine if reflux symptoms are present.
  • Quality of Life. You and your child will be asked questions to determine how significant your child’s voice difficulty is impacting their quality of life.
  • Voice Quality. Your child will complete a series of vocal tasks that allow the skilled speech-language pathologist to determine voice quality characteristics that may indicate what is causing/impacting your child’s voice quality change.
  • Acoustic Properties of Voice
  • Structural problems. All speech areas of the head and neck will be examined, including the lips, tongue, teeth, velum, and jaw, to rule out cleft palate or tongue-tie. The breath will also be evaluated to ensure that breath support is adequate to support phonation.
  • Muscle tone. The speech anatomy involved in speaking (breathing, phonating, articulating) will be examined to rule out muscle weakness or tightness.
  • Stimulability. Voice therapy requires your child to be able to follow directions, imitate models, and follow prompts and cues. Voice therapy techniques will be trialed to determine if your child can follow directions and imitate models to improve their voice quality.

If you have any specific questions about certain evaluation measures or have questions about the pertinence of a video-stroboscopy study, please feel free to call us at Kidmunicate and we will get you in touch with a skilled speech-language pathologist who can discuss this information with you.

If your child shows signs of a voice disorder or an SLP has any ear/nose/throat concerns, they may refer you to an ENT for further testing or for follow-ups as therapy progresses.

Voice Disorder Treatment

Voice Disorders are complex problems that will require significant speech-therapy with follow through outside of the treatment room. The treatment of voice disorders takes time and commitment. ASHA recommends that voice therapy be provided with certified and licensed speech-language pathologists with expertise in the behavior treatment strategies necessary to modify and improve voice quality.

It is also important to note that as a parent you will also need to be completely engaged in the process, because home practice, carryover, and caregiver models are needed to ensure a successful outcome.

Treatment approaches include:

  • Education
    • Your child will learn the basics about what the body does to create speech
      • Basic anatomy and physiology
    • To encourage vocal health, you and your child will be educated on proper vocal hygiene and how to modify your lifestyle to improve vocal health
    • Pictures, anatomy models, verbal models, and videos will be used to help your child understand the terms used for voice therapy
  • Resonance Training
    • Our SLP will have your child imitate various sounds to manipulate the laryngeal mechanism to modify the voice quality depending on the child’s area of difficulty.
    • To encourage a more efficient and healthy voice the SLP may use Lessac Madsen Resonant Voice Therapy by Katherine Verdolini Abbott
  • Breath support
    • Our SLP will provide models, visuals, and videos to teach your child how to breath efficiently to produce their best voice
    • To encourage proper vocal fold motion, your child will be taught breathing techniques to support them during moments of distress
  • Collaboration
    • Our SLP will collaborate with the family, medical professionals, and educational professionals to ensure that they find the best collaborative treatment plan for your individual child
  • Homework
    • Homework is very important for carryover and generalizations of speech therapy techniques.
      • The child with a voice disorder will need to modify their vocal hygiene and make changes in their everyday life (i.e., drink more water every day)
    • Alternative Communication
      • If your child cannot use their voice or it is too painful to use their voice, we will help create an alternative way to communicate in the meantime
      • Do not whisper* it is better to write things down or use pictures rather than whisper
    • Amplifiers
      • If your child is difficult to understand or cannot speak at a conversational loudness, we give you alternative strategies or recommend an amplifier until your child can talk at an appropriate loudness

Voice Disorder Prognosis

There is no magic cure that will heal a voice disorder. A child can grow out voice issues as a child’s behavior changes and they modify their vocal health on their own, but for the most part, some intervention is needed. Each child and their individual voice disorder varies, and therefore the prognosis, length of treatment, and overall progress varies. Voice therapy is greatly dependent on the child’s determination, concentration, intelligence, family commitment to practice at home, and co-existing issues (Autism, muscular dystrophy, etc.)

Depending on the disorder, it is possible to improve your child’s voice without surgery! Vocal fold nodules, polyps, and hemorrhages can be improved through voice therapy and dedicated follow through. It is important to see your ENT and get the help your child needs to start them on the path to better vocal health! ASHA reported that voice therapy can improve voice quality and reduce the potential for reinjure.