Pediatric dysphonia: It's not about the nodules

Efficacy and safety of acupuncture for vocal nodules: A systematic review and meta-analysis with trial sequential analysis

In this study, we aim to evaluate the efficacy and safety of acupuncture for vocal nodules, concerning qualitive overall efficacy and quantitative improvement on quality of voice. Four English and four Chinese databases were searched up to December 10th, 2022. Risk of bias among the included trials were evaluated by the Cochrane ROB tool. Systematic reviews and meta-analyses were conducted based on the Cochrane systematic review method by using RevMan 5.4 Software, and trial sequential analyses were performed by TSA 0.9. Meta-influence analyses, subgroup-analyses, meta-regression, and evaluation of publication bias were performed for exploration of heterogeneity by Stata V.14. Quality of the results was accessed through the GRADE-pro GDT. Cluster analyses and correlation coefficient were performed by R 4.1.3. Finally, 15 trials involving 1,888 participants were included. Results showed that compared with western medicine alone or Chinese herbal medicine alone, acupuncture alone yielded significantly (p<0.05) higher clinical effective rate and more improvement on scores of voice analyses. However, reduction on scores of grade, roughness, and breathiness and voice handicap index during follow-ups, and results of clinical effective rate suggested that acupuncture was inferior to voice training. In addition, meta-regression and sub-group analyses firstly revealed advanced efficacies of acupuncture when performed with local and remote acupoints, compared with local acupoints only. Acupuncture specified adverse event was denied in six trials while it was not mentioned in other nine trials. Results of cluster analyses and correlation coefficient showed that Kai yin yi hao and He gu (LI-4) were the most frequently applied matching-acupoints in trials. In conclusion, compared with western medicine (level of evidence: low ⨁⨁◯◯, GRADE C) and Chinese herbal medicine (level of evidence: moderate ⨁⨁⨁◯, GRADE B), acupuncture is safe and of better efficacy for patients with vocal nodules, while there is also need for RCTs with improvements on designing and interventions in experimental and controls.

Update on the pediatric adverse vocal behavior voice disorders: a clinical practice review

The main causes of voice disorders in children with adverse vocal behavior include benign lesions of the vocal folds caused by voice abuse or misuses, such as vocal fold nodules, vocal fold polyps, and laryngitis. Long-term voice disorders can affect the physical and mental health of children. Reviewing the literature of the last two decades on "Vocal Fold Nodules," "Vocal Fold Polyp," "Voice disorder," "Voice Abuse," "Voice Misuse," "Pediatrics," and "Children" with the appropriate Boolean operators.  Conclusion: A total of 315 results were returned on an initial PubMed search. All articles from 2000 to 2022 written in English or Chinese were screened. Duplicate articles, those relating to adults only or concerned with the malignant lesion of the vocal cord, were excluded, resulting in 196 articles of interest. Relevant references and books have also been consulted, and we provide a review of the pathogenesis, diagnosis, and treatment of these maladaptive vocal behavioral voice disorders. What is Known: • Hoarseness is the most common voice symptom in children, and there are various causes of hoarseness in children. However, there is a lack of reviews on voice disorders caused by adverse vocal habits in children. • Voice training is a conservative treatment method for children with voice disorders , and it is important to clarify the factors that influence the effectiveness of voice training for children. What is New: • This review of the personality and family characteristics of children with adverse vocal behavioural voice disorders provides a valuable guide to the clinical planning of subsequent treatment. • This article discusses and summarises some of the factors that may influence the effectiveness of voice training in children and collates some of the scales and questionnaires currently used in children that are important in predicting the effectiveness of voice training.

A Review of Voice Disorders in School-Aged Children

OBJECTIVES

The purpose of this study was to review literature concerning voice disorders in school-aged children.

STUDY DESIGN

Integrative review.

MATERIALS AND METHODS

A database search was conducted using PubMed, Web of Science, Academic Search Complete, CINAHL Complete, and Medline. All records included in this review were peer-reviewed journal articles that discussed voice disorders in children, conducted in the United States or Canada, written in English, and published between 2009 and 2019.

RESULTS

Database searching identified 1,771 records and 551 duplicates were removed. A total of 1,220 records were screened and 949 records were excluded. Two hundred and seventy-one full-text records were screened and 12 records met inclusion criteria. Vocal fold nodules were the most commonly reported vocal fold pathology. The Consensus Auditory Perceptual Evaluation of Voice and endoscopy were the most commonly reported assessments. However, variations in practice patterns and access to voice services may exist.

CONCLUSIONS

The findings highlight that school-aged children may face barriers in accessing voice services. As a result, continued analyses of the potential barriers that hinder identification and treatment of voice disorders in this population appear warranted.

Emotional Adjustment in Children with Vocal Fold Nodules

INTRODUCTION

Vocal fold nodules (VNs) in children are benign, bilateral, callous-like lesions at the junction of the anterior third and posterior two-thirds of the true vocal folds. Chronic, repetitive, and intense vocal behavior is often cited as the primary etiology; however, difficulties with emotional adjustment may predispose some children towards extreme and possibly phonotraumatic vocal activity, thereby contributing secondarily to the development of VNs.

OBJECTIVES

This case-control study examined the association between features of emotional adjustment and VNs in children.

METHODS

Parents of children with VNs (N = 40, Mage = 7.5, SDage = 2.03) and two medical control groups [ie, voice disordered, but not VNs (VDCs; N = 40, Mage= 7.09, SDage = 2.01) and vocally normal controls (VNCs; N = 40, Mage = 7.6, SDage = 1.54)] participated in the study. Features of emotional adjustment were assessed using two inventories: the Parent Rating scale for Reactive and Proactive Aggression and the Revised Child Anxiety and Depression Scale - Parent version.

RESULTS

As compared with the VNCs, children with VNs were significantly more aggressive (P = 0.042, Cohen's d = 0.47) whereas the VDCs were more depressed (P = 0.013, Cohen's d = 0.60). Furthermore, VDCs experienced more separation anxiety than VNs (P = 0.038, Cohen's d = 0.45) and VNCs (P = 0.021, Cohen's d = 0.55). No other significant between-group differences were identified between the VNs and VDCs.

CONCLUSIONS

When present, elevated aggression may represent a risk factor for VNs formation in children, and possibly influence treatment outcomes. Therefore, the current results highlight the importance of understanding the role of emotional adjustment in the evaluation and treatment of dysphonia in children.

Self-regulation in children with vocal fold nodules: A multilevel analysis

INTRODUCTION

Vocal fold nodules (VNs) represent the most common cause of voice disorders in children. Phonotrauma related to chronic, repetitive, intense vocal activity is often cited as the proximate cause of VNs. However, diminished self-regulation (SR) may predispose some children toward extreme phonotraumatic voice use, thereby contributing secondarily to their development. This case-control study examined the association between features of SR and VNs in children.

METHOD

Parents of children with VNs (N = 40, Age Mean = 7.5, SD = 2.03 years) and vocally normal, medical controls (VNCs; N = 40, Age Mean = 7.6, SD = 1.54 years) completed the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2; Gioia, Isquith, Guy & Kenworthy, 2015), an inventory that evaluates components of SR in children.

RESULTS

Children with VNs, as compared with the vocally normal control group, were described as (i) impulsive (i.e., scoring significantly worse on the Behavior Regulation Index, BRI; P < 0.001, Cohen's d = 0.86), and (ii) emotionally dysregulated (i.e., scoring significantly worse on the Emotional Regulation Index, ERI; P < 0.001, Cohen's d = 0.81).

CONCLUSIONS

Diminished SR in some children with VNs may contribute to phonotraumatic vocal behaviors and potentially attenuate the effectiveness of voice therapy.

Assessment of auditory processing in childhood dysphonia

INTRODUCTION

Clinical experience shows that children with functional dysphonia often present disorders that are associated with abnormal auditory and emotional development. These children also struggle with voice therapy, perhaps because of difficulties with auditory control during speech. It has been hypothesized that difficulties in auditory processing in children may be an important factor in the pathogenesis of childhood dysphonia.

OBJECTIVE

The study aimed to assess selected auditory functions in children with hyperfunctional dysphonia.

MATERIALS AND METHOD

The study group consisted of 331 children aged from 7 to 12 years suffering from hyperfunctional dysphonia. The control group consisted of 213 children aged 7-12 years. All patients underwent ENT and phoniatric examination. All children underwent two standardized psychoacoustic tests: the Frequency Pattern Test (FPT) and the Duration Pattern Test (DPT).

RESULTS

In the examined material, 223 children had edematous vocal fold nodules. The largest statistically significant differences were seen in the acoustic parameters describing relative frequency changes. FPT and DPT showed statistically significant differences in children with hyperfunctional dysphonia compared to the control group. At all ages the percentage of correctly identified tone sequences was significantly lower in children with dysphonia.

CONCLUSION

Children with hyperfunctional dysphonia have difficulties in judging the pitch and duration of auditory stimuli. Difficulties in auditory processing appear to be important in the pathomechanism of functional voice disorders. Impaired hearing processes in children with hyperfunctional dysphonia can make it difficult to obtain positive and lasting effects from voice therapy.

Personality in Children With Vocal Fold Nodules: A Multitrait Analysis

Purpose Vocal fold nodules (VNs) are bilateral, symmetrical, callous-like lesions secondary to phonotrauma and possibly related to specific personality traits. This case-control study examined the relation between personality and VNs in children within the context of the Trait Theory of VNs. Method Parents of children with VNs (N = 39, M = 7.43, SD = 2.01 years) and two medical control groups (i.e., voice disordered controls, but not VNs [VDCs; N = 40, M = 7.09, SD = 2.01 years] and vocally normal controls [VNCs; N = 40, M = 7.6, SD = 1.54 years]) completed the Inventory of Child Individual Differences, a personality instrument that describes the Big Five superfactors as well as 15 lower order personality traits. Results Children with VNs, as compared with VNCs, were (a) emotionally reactive (i.e., higher N-Neuroticism, p < .005, Cohen's d = 0.53), (b) Antagonistic, Strong-Willed, and less Compliant (i.e., lower A-Agreeableness, p < .014, Cohen's d = 0.59), and (c) Distractible and Disorganized (i.e., lower C-Conscientiousness, p < .009, Cohen's d = 0.62). Both voice disordered groups displayed elevated scores on the personality superfactor of Neuroticism (N; and the "Negative Emotions" lower order trait). Conclusions The combination of personality traits identified in this study (i.e., high N, low A and C) may play a central role in VNs development and possibly attenuate voice therapy success. Children with VNs displayed a similar personality typology as women with VNs, with the exception of elevated Extraversion (E), thereby providing support for the relevance of the Trait Theory of VNs in both children and adults. Clinicians treating children with voice disorders, including VNs, should consider their underlying personality traits in assessment and management.

Voice disorders in children starting school education

&lt;b&gt;Introduction: &lt;/b&gt;Voice disorders in children especially in the school-age period comprise a major and challenging medical, social and educational issue. There is a lack of epidemiological data regarding children's voice in Poland which limits the development of preventive and medical pediatric procedures in our country. &lt;br&gt;&lt;b&gt;Objective:&lt;/b&gt; The aim of study was to determine the prevalence of voice disorders in children starting school education in Mazovia. &lt;br&gt;&lt;b&gt;Material and method:&lt;/b&gt; The study was a retrospective analysis of survey data from parents of children attending the first grade of primary school. The survey consists of five questions describing the voice. A statistical analysis of 7891 questionnaires was carried out. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; Analysis of the survey showed a prevalence of dysphonia in 12.8% children aged 7 starting primary school. In this study, voice disorders were observed more often in boys (14.6%) than girls (10.8%). The authors presented the correlation between voice disorders and the expression of emotions. &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; Studies have shown that the percentage of children with voice disorders is significant in our country. The survey regarding voice in school children in Mazovia shows preliminary results of voice disorders in the pediatric population in Poland.