Pediatric Voice Disorders - An Overview

Introduction

Voice is the primary means of communication and is considered one’s identity. With the help of voice, gender, age, and health can also be estimated. Voice refers to vocalization or sounds that are produced by the vibration of vocal folds. The abnormality in voice quality is considered responsible for negative attention and also limited participation in social gatherings. The entire speech production system is responsible for any changes in vocal activity. It involves phonation, respiration, and articulation. The common causes of pediatric voice disorders are discussed in this article.

Anatomy and Physiology of Vocal Activity

The larynx and the human vocal tract significantly change from childhood to adult. The child's larynx's anatomy is considered a miniature adult larynx. The pediatrician called so while treating any laryngeal disorder. The larynx is placed higher during childhood than its position in adults. This high placement of the larynx is beneficial for the simultaneous coordination of respiration and swallowing in an infant. The movement of the larynx to a lower position occurs while growing into an adult. This change doesn't cause any change to phonation but the resonance of the voice. The larynx grows rapidly till age three and then decreases in size. Then, it grows rapidly during adolescence and on reaching puberty. Until the reach of puberty, the larynx is the same in boys and girls, and the voice also doesn't differ much in both.

What Are the Causes of Voice Disorders in Children?

There are various causes that lead to changes in the structure and function of the larynx in children. The cause can be infectious, inflammatory, neurological, congenital, or iatrogenic.

• Inflammatory Nodules: Approximately 70% of the cases of voice disorder in pediatric patients are caused by nodules on vocal cord folds. These nodules are usually inflammatory. The mid-membranous part of the vocal fold usually bears these nodules. The abnormalities caused by these nodules include abnormal glottic closure and abnormal vibration of the vocal fold. The abnormal vocal fold vibration caused by these inflammatory nodules leads to a change in voice that we usually refer to as hoarseness of the voice.

• Papillomas: Respiratory papillomas are the most common benign tumors of the larynx seen in children. These cause respiratory distress, hoarseness, and stridor. In these cases, surgical interventions are essential to maintain a normal airway. The presence of papillomas causes voice disorder in the affected child because it interferes with the vocal fold vibration. These papillomas recur frequently and are usually surgically removed. In the case of remission of these respiratory papillomas, the voice disorder can also be because of the complication of the previous surgery. The surgery for the removal of excessive papillomas is extensive and may get complicated because of the chances of injuring the vocal folds. The soft tissue complications associated with the surgical removal of the papillomas are increased in children who require more than six laser procedures to remove previously present papillomas.

• Congenital Glottic Web: this is a rare condition seen in children. This is associated with voice disorders at the time of birth. Cohen had an extensive study on these glottic webs. It was reported that if the web extension does not cover 35% of the airway, then no treatment was required. In cases where the extension of the glottic web exceeded and covered more than 50% of the airway, surgical intervention was necessary, and a tracheostomy was performed in the child. Treatment options also included endoscopic treatment of the glottic web with dilation and laser therapy. The placement of Teflon keel is also considered to treat the glottic web. It is usually recommended to wait till age three until the larynx is fully developed.

• Gastroesophageal Reflux Disease: GERD is a common disorder that is present in both children and adults. Adults who suffer from GERD have associated voice disorders. The connection between GERD and pediatric voice change is not well known, but the association with reflux-related laryngitis is seen in many cases with voice change in children. This condition is diagnosed by examining the larynx and visualization of erythema in the larynx.

What Is the Treatment of Voice Disorders in Children?

The treatment of voice disorders in children depends on the cause and severity of the case.

• Cysts: In the case of vocal fold cysts, the treatment option is the surgical removal of the cyst from the submucosal layer without injuring any surrounding tissue or structure.

• Papillomas: In recurrent papillomas, the treatment option is a surgical intervention without injuring any surrounding structure. This affects both the speech and respiration of the child.

• Vocal fold nodules: Behavioural voice treatment is also considered in the presence of vocal fold nodules.

• Conservative treatment: In the case of voice disorders, the traditional and conservative method of treatment includes maintaining vocal hygiene and reducing abusive behavior such as yelling or shouting. The traditional approaches do not work well for specific reasons such as:

  • Children see their friends using abusive behaviors, such as yelling, without having any adverse effects

  • The child does not tend to manage behavior by traditional methods.

  • Children with congenital voice disorder probably never experienced normal voice, so it is difficult to motivate them to change their behavior.

The treatment options should focus on improving the voice quality and establishing motivation for a child to cooperate with the treatment. The techniques used to treat voice disorders in children are similar to those used in adults. The treatment for children should include friendly language, and attempts to involve their caregiver are also helpful. Vocal functional exercise, resonant voice therapy, and diaphragmatic breathing are implemented in children with voice disorders.

Conclusion

Voice disorders in children impact their communication skill development. The otolaryngologist should perform tests and make an early diagnosis of the cause of the disorder. The focus should be on establishing the voice quality and making the child cooperate with the physician. The parent or the caregiver recognizes the disorder, but the treatment and outcome depend on the pediatrician.