Prevalence of Hoarseness in School-aged Children

The prevalence and risk factors of hoarseness among pupils in elementary schools in the South of Finland

Purpose: Hoarseness and voice problems are one of the chronic conditions experienced by children. The aim of this study was to investigate the prevalence of hoarseness, possible risk factors and effects of the remediation of school buildings to the prevalence of hoarseness among school children. Methods: The material was gathered from all the schools in a large city in the south of Finland and the collection method used was an e-mail survey sent to the parents of the pupils and a simultaneous survey sent to the personnel in the schools. Results: All 51 schools participated, and 5889 pupils returned the questionnaire (39%). The exposure data was obtained from two building experts who knew the repair history of the schools. A subjective estimation of the quality of the indoor air was obtained from teachers and the parents. The overall prevalence of hoarseness among pupils was 6.3%; prevalence being higher in unrepaired school buildings than in schools in a good condition or buildings with a thorough remediation. Hoarseness was associated with asthma and allergies, several respiratory symptoms, and respiratory infections. Exposure to tobacco smoke increased the risk, and consumption of caffeine containing drinks seemed to reduce the risk. Noise, stuffiness of the indoor air and microbial smells correlated strongly with the occurrence of hoarseness in a logistic regression model when controlled for age, gender, asthma, passive smoking, and caffeine consumption. Conclusions: We recommend renovations in school buildings with the aim of providing better acoustics, sufficient ventilation, and a reduction in exposure to moisture damage microbes.

Analysis of 1782 Pediatric Hoarseness Cases: A Clinical Retrospect Study

OBJECTIVE

This study aims to clarify the clinical characteristics of pediatric voice disorders.

METHODS

The clinical data of 1782 pediatric patients presenting with voice disorders were retrospectively analyzed. These cases were categorized into four age-based cohorts: 0-3, 4-7, 8-11, and 12-15years. Variables such as gender disparities, laryngoscopic manifestation, disease types, and acoustic parameters were thoroughly examined.

RESULTS

A total of 1782 children with acoustic hoarseness were included in this study, comprising 1325 males and 457 females. When the sex ratio among the children in each group was compared, males were found to outnumber females. A notable male predominance was observed across all age groups. Laryngoscopic results revealed that the most prevalent condition was vocal cord nodules (1363 cases, 76.48%), followed by vocal cord polyps (271 cases, 15.20%). Other diseases included laryngeal papillomas, vocal fold movement impairment, vocal cord cysts, functional dysphonia, leukoplakia of the vocal cords, and benign laryngeal tumors such as laryngeal amyloidosis and subglottic granular cell tumors. Among these, adenoid hypertrophy was presented in 382 children (21.44%). Additionally, the Reflux Finding Score (RFS) was conducted, and 799 cases (44.83%) were found to have a score above 7. The distribution of various diseases across different age groups indicated that children with vocal cord nodules (637 cases, 46.74%), vocal cord polyps (109 cases, 40.22%), and laryngeal papillomas (35, 36.84%) were predominantly found in the 4-7 years age group. Pediatric acute laryngitis (three cases, 75%) and vocal fold movement impairment (eight cases, 36.36%) were more common in the 0-3 years age group. Functional dysphonia (four cases, 66.67%) and vocal cord leukoplakia (four cases, 80%) were mainly observed in the 12-15 years age group, while vocal cord cysts were predominantly seen in the 8-11 years age group (four cases, 57.14%). A comparative analysis of acoustic parameters among 153 children showed statistically significant differences in jitter, fundamental frequency (F0), voice handicap index (VHI), reflux symptom index (RSI), and RFS across different pathologies.

CONCLUSION

This study highlighted that vocal cord nodules, vocal cord polyps, and laryngeal papillomas were the primary causes of pediatric hoarseness, although the possibility of tumors and rare diseases cannot be disregarded. There was a noticeable gender bias towards males, and functional dysphonia was significantly more prevalent in older children.

Voice Disorder Prevalence and Vocal Health Characteristics in Children

Importance

Voice disorders impede communication and limit quality of life for many children. However, research demonstrating the prevalence of pediatric voice problems and associated voice use patterns is scarce. This investigation examined the prevalence of voice problems and vocal health characteristics of school-aged children.

Objective

To examine the prevalence of voice problems in school-aged children throughout the US with reference to lifestyle, demographic characteristics, and voice use patterns.

Design, Setting, and Participants

This study used a cross-sectional design to survey a probability sample of caregivers of children aged 4 to 12 years living throughout the US in 2023.

Main Outcomes and Measures

Caregivers were surveyed regarding their children's voice use, voice symptoms, voice problems, extracurricular activities, and demographic information. Caregivers also competed the Pediatric Voice-Related Quality of Life questionnaire. The Fisher exact test, χ2 tests, and logistic regression were used to compare children with and without voice problems.

Results

Overall, 6293 panelists were invited to complete screening questions for the survey, and 1789 individuals were screened for eligibility between March and April 2023. Of these, 1175 parents (65.7%) completed the survey. Twenty-one (1.8%) were excluded for a combination of either high refusal rates (n = 16), speeding (n = 2), or straight lining (n = 12). The final number of participants included in analysis was 1154 caregivers of children aged 4 to 12 years (559 female children [48.4%]; 595 male children [51.6%]; mean [SD] age, 8.02 [2.49] years). The prevalence of voice problems in children was 6.7% (n = 78), and the lifetime prevalence was 12% (n = 138). Benign vocal fold lesions was the most common diagnosis underlying voice complaints, and other causes included respiratory illness, allergies, autism-related voice issues, and other neurological conditions. Risk factors for pediatric voice problems included being male (odds ratio [OR], 1.47; 95% CI, 1.0-2.1), having more than 4 individuals living in the household (OR, 2.30; 95% CI, 1.2-4.4), poor speech intelligibility (OR, 2.26; 95% CI, 1.2-4.3), maternal history of voice problems (OR, 4.54; 95% CI, 1.2-16.4), participating in online gaming (OR, 1.56; 95% CI, 1.0-2.3), and secondhand smoke exposure (OR, 1.7; 95% CI, 1.1-2.6). Voice use-related risk factors included frequent talking, coughing, throat clearing, tantrums/crying, and vocal strain. Voice problems were associated with substantially detracted quality of life as measured by the Pediatric Voice-Related Quality of Life questionnaire, limited social/extracurricular interactions, increased school absences, and negative attention from adults.

Conclusions

The results of this survey study suggest that pediatric voice problems are relatively common and detract from quality of life. Specific environmental and behaviorial factors are associated with increased risk for voice disorders.

The Effect of An Indirect Voice Therapy Approach on the Voice of Children With Vocal Fold Nodules: A Prospective Cohort Study

PURPOSE

To investigate the effect of a combination indirect voice therapy approach on the management of vocal nodules in the pediatric population.

METHODS

A prospective cohort study with thirty children (24 males and 6 females; mean age 8.8 ± 2.2) with a diagnosis of vocal fold nodule (VFN) was conducted. All participants were included in an 8-week voice therapy program consisting of vocal hygiene education and parental rule-setting. Videolaryngoscopic examination, auditory-perceptual evaluation, and acoustic voice analysis were performed immediately before and after the intervention.

RESULTS

The comparison of videolaryngoscopic findings before and after the therapy revealed that the size of the nodules decreased significantly (P < 0.001). Findings from the laryngeal examination showed that the vast majority of children 73.3% (n = 22) had no VFN anymore after the intervention. The auditory-perceptual evaluation showed that overall severity of dysphonia decreased significantly [from 50 (40-70) to 38 (30-45), P < 0.001]. Jitter local (P = 0.031) and Jitter local abs (P = 0.043) parameters statistically differed after the therapy. There were not any statistically significant differences for mean F0, shimmer local (%), shimmer local (dB), and mean HNR.

CONCLUSIONS

The voice therapy method in this study has a clear benefit on the voice of children with VFN and can be used in clinical practice. Specifically, clinicians should consider the parents as a core component of voice therapies and pay attention to vocal hygiene education for optimal management of VFN related childhood dysphonia.

Prevalence and Risk Factors for Dysphonia in Preschoolers at Five Years Old in a Capital City in the Northeast of Brazil

GOALS

Identifying the prevalence and risk factors of childhood dysphonia in children turning 5 years old; and assess the link with the interactional, behavioral, sociodemographic, economic, and biological indicators METHOD: Analytical, transversal, nested within a birth cohort 5 years after its creation. Original cohort biologic data were recovered from the previous database. The current demographic and personal data were acquired from the official health institutions where the individuals were found. We managed to find 371 preschoolers, both sexes, enrolled in 141 public and private schools. Face-to-face interviews were performed with mothers regarding maternal and child health and biological, sociodemographic, economic, interactional-affective, and behavioral indicators. Speech therapists used the Consensus of Auditory-Perceptual Evaluation of Voice authorized for Portuguese for the perceptual-auditory judgment of children's voices. Bivariate and multivariate analyzes of the data were performed. A significance level of 5% (P < 0.05) was considered in all analyses.

RESULTS

The prevalence of mild-moderate general dysphonia occurred in 26.4% of the preschoolers assessed with tense, rough, and breathy voice quality; low pitch; strong loudness and laryngeal resonance. There was a contrast between preschoolers with dysphonia, calm temperament, and family income of up to three minimum wages and those without these characteristics. We also have noted that a greater chance of dysphonia occurred in preschoolers with a calm temperament, family income of up to three minimum wages, nocturnal bruxism up to 3 years old and who did not use a pacifier.

CONCLUSION

There was a high prevalence of dysphonia at 5 years old. Biological indicators have an impact on voice, while interactional, behavioral, sociodemographic, and economic indicators have a higher impact. There is a great need for investments in prevention, promotion, and vocal treatment to minimize negative socio-educational impacts and provide higher quality of life for children at greater risk for dysphonia.

Development and Validation of the Children's Voice Questionnaire (CVQ)

OBJECTIVES

This study developed and validated the children's voice questionnaire (CVQ), a new self-administered instrument for children, and evaluated its internal consistency and reliability.

STUDY DESIGN

Observational, prospective, cross-sectional study.

METHODS

The initial preparation of the CVQ was conducted in four steps. First, individual interviews were conducted with dysphonic and non-dysphonic children and their parents, teachers, and speech pathologists. Second, the responses collected from the interviews were arranged into a comprehensive list of 175 items. Third, this list was reduced to a preliminary 21-item version of the questionnaire, which was tested as a pilot with 254 children. Fourth, a further reduction to 18 items was performed to construct the final version of the CVQ. The questionnaire was then administered to 342 children (73 dysphonic, 269 non-dysphonic) aged 6-18. Simultaneously, the parents of these children completed the pediatric voice handicap index (pVHI). Finally, after 2 weeks, 30 randomly selected children (nine dysphonic, 21 non-dysphonic) completed the CVQ again to evaluate test-retest reliability.

RESULTS

High reliability was found for the CVQ (Cronbach's α = 0.94). Test-retest revealed strong and statistically significant reliability (r = 0.79, P < 0.001). A highly significant group difference was found between the CVQ scores obtained for the dysphonic and non-dysphonic groups (t[78.25] = 6.22, P < 0.001). In addition, significant medium-to-strong positive correlations were found between the children's evaluations using the CVQ and their parents' evaluations using the pVHI (0.59 < r < 0.66, P < 0.01).

CONCLUSIONS

The newly developed CVQ is a valid and reliable instrument. Findings reveal general agreement between children and their parents, but also show that children's perspective on their dysphonia is not equivalent to the parent's perspective. This demonstrates that combining both perspectives provides a more holistic and complete overview of dysphonic children's voice-related quality of life. The self-administered CVQ reliably differentiates dysphonic from non-dysphonic children and may serve as a valuable tool for the initial or ongoing evaluation of children with voice disorders in clinical and research settings.

The Acoustic and Perceptual Correlates of Gender in Children's Voices

PURPOSE

This study investigates the perceptual and acoustic correlates of gender in prepubertal voices. The study is part of a longitudinal project analyzing recordings of circa 60 German primary school children from the first to fourth grades (6- to 10-year-olds).

METHOD

Spontaneous and content-controlled audio recordings were made of 62 first-grade children (29 girls, 33 boys; age: 6- to 7-year-olds) from two German primary schools. Information on gender conformity was also recorded. A total of 167 listeners judged the gender of the voices on a 7-point scale. The results of the listening experiments and gender conformity ratings were related to a range of typical acoustic parameters.

RESULTS

Measures of self-reported gender conformity differ significantly between the boys and the girls. Sixteen of the 62 children show unambiguous gender attributions in the listening experiment. A hierarchical cluster analysis including gender perception, gender conformity, and acoustic parameters shows four different types of speakers. Two multiple regression models revealed a significant main effect of fundamental frequency on the gender perception ratings of the listening experiment across and within gender. Significant correlations were found between the center of gravity and skewness of the sibilants and gender conformity, especially for the male speakers.

CONCLUSIONS

Fundamental frequency plays an important role in influencing perceptual judgments, whereas sibilant spectra are correlated with gender conformity. In further listening experiments, we will examine in more detail the role of individual acoustic parameters and analyze how the vocal expression of gender and gender conformity in individual children develops before reaching puberty.

The Occurrence of Laryngeal Pathologies in a Treatment-Seeking Pediatric Population

OBJECTIVES

The purpose of this study was to 1) describe the age- and sex-specific occurrence of laryngeal pathologies in a treatment-seeking pediatric population in the voice unit of Ghent University Hospital, Belgium, and 2) describe this population in terms of vocal parameters, vocal complaints, influencing factors, and treatment history and recommendation.

STUDY DESIGN

Retrospective, observational study.

METHODS

All patient records were analyzed for children (0-18 years) who consulted the ear, nose, and throat department of Ghent University Hospital for the first time between July 2015 and June 2021 with complaints of dysphonia. In total, 103 children (66 males, 37 females) with a mean age of 10.01 years (SD: 3.4, range 3.93-17.96) were included in this study. Laryngeal pathology was diagnosed using a flexible videolaryngo(strobo)scopy. The influence of age and sex on laryngeal etiology (organic/functional voice disorder) was examined using a Welch-modified t test and a Fisher's exact test, respectively.

RESULTS

Organic lesions were observed in 77.7% of the participants, with vocal fold nodules (VFNs) being the most common diagnosis (66.0%). A functional voice disorder was diagnosed in 22.3% of the children. Children with a functional voice disorder are significantly older than children with an organic voice disorder. There was no statistically significant difference between males and females in laryngeal etiology. Mean dysphonia severity index was -2.7 (SD: 3.2, range -9.3 to +3.7), the mean acoustic voice quality index 4.70 (SD: 1.5, range 2.35-8.27), and the mean pediatric voice handicap index 29.8 (SD: 13.6, range 5-60). The occurrence of vocal misuse was mentioned in 80.6% of the patient records.

CONCLUSION

Organic voice disorders, especially VFNs, are predominant in treatment-seeking children with dysphonia. Functional voice disorders become more common with increasing age during childhood. A disordered vocal quality, reduced vocal capabilities and reduced voice-related quality of life were found.

Pediatric Dysphonia and the Access to Voice Therapy: A Study in Speech Therapy Services Available in a Capital City in the Northeast of Brazil

OBJECTIVES

Defining the laryngeal and vocal alterations in the pediatric group studied in private speech therapy facilities; and estimating the time period between the problem being identified by the parents and the access to the proper provided services.

METHODS

A cross-sectional analytical observational research with data collected from medical records by the speech therapist of each private facility. A written form was prepared and sent to the speech therapists of the 40 existing facilities. We received 124 of them from the pediatric group being assisted in 15 of the facilities. The form included questions about gender, age, vocal complaints; general degree of dysphonia; otorhinolaryngological diagnosis of vocal fold alterations; the age that the problem was identified by the parents and the beginning of speech therapy. The larynx was examined by videonasopharyngolaryngoscopy, and voice quality by auditory-perceptual assessment.

RESULTS

The time period between the identification of the participant's dysphonia by the parents and the start of speech therapy was considered long (3.5years). The group showed variance in the proportion of nodule and cyst between genders. The highest prevalence of nodules occurred in boys; and the cyst in girls. Moderate general dysphonia occurred between 4 and 17years old, average age of 7years and 7months, with greater distribution between 5 and 10years of age.

CONCLUSIONS

The average time delay until the start of speech therapy was 3.5years, more frequently in the 5-10years group and due to nodules in boys and cysts in girls.

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.

Management of Pediatric Voice Disorders: Perceived Knowledge, Confidence, Attitude and Practice Patterns Among School-based Speech-language Pathologists in Hong Kong

OBJECTIVE

This survey evaluated the levels of self-perceived knowledge, confidence, attitude and practice patterns of school-based speech-language pathologists (SLPs) in Hong Kong regarding their management of pediatric voice disorders.

METHODS

SLPs with experience working in school settings in Hong Kong were invited to complete an anonymous online survey. The survey ascertained SLPs' perception of their knowledge, confidence, attitude and practice patterns regarding their management of pediatric voice disorders. It also explored the barriers and facilitators to effective service provision for children with voice problems in schools.

RESULTS

A total of 85 responses were received, of which 56 respondents with complete responses were selected for analysis. Results showed that respondents in general did not consider themselves having sufficient knowledge on pediatric voice. They did not feel fully confident in managing pediatric voice cases. Even though they exhibited a positive attitude and agreed that pediatric voice management was important, discrepancies were noted between their attitude and practice. Barriers that hinder practice include the lack of professional guidelines, insufficient time and resource as well as difficulties to conduct comprehensive voice assessments with children.

CONCLUSION

The study findings urge the needs of enhancing school-based SLPs' perceived knowledge and competence in managing pediatric voice disorders. The study also identifies strategic directions to improve service provision for children with voice disorders in schools.

Hoarseness Among Young Children in Day-Care Centers

BACKGROUND

Chronic respiratory symptoms among toddlers are assumed to be due to allergies and common respiratory infections. Because symptoms and respiratory disease in this age group often continue on to school age and later life, it is important to know the possible risk factors for prevention of the chronic hoarseness.

AIM

We aimed to determine the current prevalence of hoarseness and other chronic respiratory symptoms among toddlers and young children. Another aim was to examine the risk factors for hoarseness in the building environments of day-care centers (DCC).

MATERIAL

An electronic symptom survey was sent to all parents of children in day-care centers of a large city in southern Finland. In all, 3721 individuals completed the questionnaire (38%), 53.4% were the parents of boys and 46.6% girls.

RESULTS

The prevalence of hoarseness was 5.6%. The boy's parents reported hoarseness more often than the girls, but no significant difference was observed. Risk factors for hoarseness in a built environment in this age group were noise, visible dust and dirt, mold and a cellar like odor, a sewer smell, other unpleasant smells, stuffiness of the indoor air, a too high or too low temperatures, a cold floor, insufficient ventilation, the age of the DCC building, and wood as the bearing construction of the building. The lifestyle factors that correlated with the prevalence of hoarseness were the amount of time spent outdoors; however, passive smoking, the number of siblings and pets at home did not correlate with hoarseness. Hoarseness was significantly correlated with other chronic respiratory symptoms such as rhinitis, coughs, eye irritation, tiredness, headaches, and stomach problems and also with the regular or periodic use of medication. Hoarseness was also significantly correlated with asthma and allergic rhinitis and also with repeated infections, such as a common cold, cold with a fever, laryngitis, otitis media and acute bronchitis, but not with tonsillitis or pneumonia. When potential confounders had been controlled for with a logistic regression model, the following risk factors in the built environment remained statistically significant: noise, high room temperature, insufficient ventilation and the stuffiness of the indoor air, a solvent odor, wood as the bearing construction and the age of the building.

CONCLUSIONS

We conclude that in day-care centers, buildings should be maintained, cleaned and ventilated properly. Concrete and brick used in the construction were protective compared with wood. The acoustic environment should be planned to reduce noise indoors and solvent based chemicals should be avoided. Neither having pets at home or the number of siblings were risk factors, but they were also not found to be protective in this material. All measures that reduce the occurrence of respiratory infections probably also reduce chronic voice problems.

Validity and Reliability of the Dutch Children's Voice Handicap Index-10

OBJECTIVES

Voice-related quality of life (Qol) questionnaires provide the clinician with information regarding the impact of voice disorders on the patient's well-being. The available voice-related QoL tools for Dutch-speaking children are parent-proxy in nature. However, the use of proxy measurements has been debated in the literature. The Children's Voice Handicap Index-10 (CVHI-10) is a self-reported QoL tool for dysphonic children. Therefore, the aim of this study is to develop and validate a Dutch version of the CVHI-10.

STUDY DESIGN

Observational, prospective, cross-sectional study.

METHODS

The original version of the CVHI-10 was translated and adapted to Dutch according to the recommendations of the Quality of Life Special Interest Group - Translation and Cultural Adaptation group. Subsequently, the questionnaire was individually completed by 77 children (dysphonic group: n = 30, control group: n = 47) between eight and 14 years. In order to investigate test-retest reliability, 50% of the participants were asked to complete the questionnaire twice with an interval of 2 weeks. Internal consistency, test-retest reliability and construct validity were calculated. A receiver operating characteristic (ROC) analysis was conducted to check the sensitivity and specificity levels of the instrument.

RESULTS

Internal consistency measured with Cronbach's alpha coefficient was 0.745. Test-retest reliability measured with intraclass correlation coefficients was 0.718. Mean total CVHI-10 score was 6.17 ± 2.7 in the dysphonic group and 2.68 ± 2.6 in the control group. The difference in total score between the groups was statistically significant (P < 0.001), suggesting that the tool has good construct validity. ROC analysis demonstrated moderate diagnostic accuracy (area under the curve = 0.869) and suggested a cut-off score of 3.5.

CONCLUSIONS

The Dutch CVHI-10 is the first self-reported voice-related QoL tool for dysphonic Dutch-speaking children. It is a valid, reliable and sensitive tool to assess the impact of a voice disorder on the child's well-being.

Prevalence and Determinants of Hoarseness in School-Aged Children

Hoarseness in school-aged children may affect their educational achievement and interfere with their communication and social skills development. The global prevalence of hoarseness in school-aged children ranges between 6% and 23%. To the best of our knowledge, there is a scarcity of studies describing the prevalence or determinates of hoarseness in Saudi school-aged children. Our aim was to measure the prevalence of hoarseness among school-aged children and to identify its determinants. A cross-sectional questionnaire-based survey was used that included randomly selected primary and early childhood schools from private and governmental sectors in Saudi Arabia. The data were collected using a questionnaire which was self-completed by the children's parents and covered the following aspects: sociodemographic features, health and its related comorbidities about children and their families, attendance and performance in school, child's voice tone, past history of frequent crying during infancy, history of letter pronunciation problems and stuttering, the Reflux Symptom Index (RSI) and the Children's Voice Handicap Index-10 for parents (CVHI-10-P). Determinants of hoarseness were investigated using the SPSS software (version 20). The mean age of the study children (n = 428) was 9.05 years (SD = 2.15), and 69.40% of them were male. The rate of hoarseness in the participants was 7.5%. Hoarseness was significantly common in children with a history of excessive infancy crying (p = 0.006), letter pronunciation issues (especially 'R' and 'S'; p = 0.003), and stuttering (p = 0.004) and in those with a previous history of hoarseness (p = 0.023). In addition, having the symptoms of gastrointestinal reflux increased the risk of hoarseness by four times (OR = 4.77, 95% CI = 2.171, 10.51). In summary, hoarseness in children may be dangerously underestimated, as it may reflect the presence of speech problems, in addition to the presence of laryngopharyngeal reflux (LPR). Hoarseness was assumed on the basis of parental complaints. Therefore, further research with diagnoses based on a clinical assessment is needed to understand the magnitude of the hoarseness problem and its consequences in children.

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.

Development, Validation, and Reliability of the Teacher-Reported Pediatric Voice Handicap Index

PURPOSE

The purpose of this study was to develop a novel teacher-reported pediatric voice outcome measure and to investigate its psychometric properties.

METHOD

In the first stage, a new instrument, the Teacher-Reported Pediatric Voice Handicap Index (TRPVHI), was developed. After item generation, a panel of experts evaluated the items to assess the content validity. Subsequently, the final version of the preliminary instrument was applied to teachers of 306 children (57 dysphonic and 249 vocally healthy) between the ages of 4 and 11 years. Eventually, the construct validity, criterion-related validity, test-retest reliability, and internal consistency of the developed instrument were examined.

RESULTS

The items with a content validity ratio less than .8 were modified or removed, and accordingly, the preliminary version of the index was finalized. After the application of the preliminary version, item reduction was made based on the factor analysis. The index is composed of 27 questions and three subscales: Functional, Physical, and Emotional. A significant difference was observed between the dysphonic and vocally healthy children for the TRPVHI scores (p < .001). A positive moderate correlation was determined between the Pediatric Voice Handicap Index and TRPVHI scores. Correlation coefficients between the test and retest scores of the TRPVHI were in the range of .92-.98. Cronbach's alpha values computed to assess the internal consistency were in the range of .94-.98.

CONCLUSIONS

The TRPVHI is the only valid and reliable teacher-reported outcome measure of the effects of voice disorders on children. It is anticipated that the deployment of the TRPVHI in conjunction with other subjective tools, both in the initial evaluation and the follow-up of the treatment results, will allow a better understanding of the physical, functional, and emotional effects of voice disorders on children. Furthermore, it can potentially lead further research to enable the use of the TRPVHI for screening purposes.

Quantitative and Qualitative Electroglottographic Wave Shape Differences in Children and Adults Using Voice Map-Based Analysis

Purpose The purpose of this study is to identify the extent to which various measurements of contacting parameters differ between children and adults during habitual range and overlap vocal frequency/intensity, using voice map-based assessment of noninvasive electroglottography (EGG). Method EGG voice maps were analyzed from 26 adults (22-45 years) and 22 children (4-8 years) during connected speech and vowel /a/ over the habitual range and the overlap vocal frequency/intensity from the voice range profile task on the vowel /a/. Mean and standard deviations of contact quotient by integration, normalized contacting speed, quotient of speed by integration, and cycle-rate sample entropy were obtained. Group differences were evaluated using the linear mixed model analysis for the habitual range connected speech and the vowel, whereas analysis of covariance was conducted for the overlap vocal frequency/intensity from the voice range profile task. Presence of a "knee" on the EGG wave shape was determined by visual inspection of the presence of convexity along the decontacting slope of the EGG pulse and the presence of the second derivative zero-crossing. Results The contact quotient by integration, normalized contacting speed, quotient of speed by integration, and cycle-rate sample entropy were significantly different in children compared to (a) adult males for habitual range and (b) adult males and adult females for the overlap vocal frequency/intensity. None of the children had a "knee" on the decontacting slope of the EGG slope. Conclusion EGG parameters of contact quotient by integration, normalized contacting speed, quotient of speed by integration, cycle-rate sample entropy, and absence of a "knee" on the decontacting slope characterize the wave shape differences between children and adults, whereas the normalized contacting speed, quotient of speed by integration, cycle-rate sample entropy, and presence of a "knee" on the downward pulse slope characterize the wave shape differences between adult males and adult females. Supplemental Material https://doi.org/10.23641/asha.15057345.

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.

Establishing Normative Data on Singing Voice Parameters of Children and Adolescents with Average Singing Activity Using the Voice Range Profile

PURPOSE

The purpose of this study was to establish and characterize age- and gender-specific normative data of the singing voice using the voice range profile for clinical diagnostics. Furthermore, associations between the singing voice and the socioeconomic status were examined.

METHODS

Singing voice profiles of 1,578 mostly untrained children aged between 7.0 and 16.11 years were analyzed. Participants had to reproduce sung tones at defined pitches, resulting in maximum and minimum fundamental frequency and sound pressure level (SPL). In addition, maximum phonation time (MPT) was measured. Percentile curves of frequency, SPL and MPT were estimated. To examine the associations of socioeconomic status, multivariate analyses adjusted for age and sex were performed.

RESULTS

In boys, the mean of the highest frequency was 750.9 Hz and lowered to 397.1 Hz with increasing age. Similarly, the minimum frequency was 194.4 Hz and lowered to 91.9 Hz. In girls, the mean maximum frequency decreased from 754.9 to 725.3 Hz. The mean minimum frequency lowered from 202.4 to 175.0 Hz. For both sexes, the mean frequency range ∆f showed a constant range of roughly 24 semitones. The MPT increased with age, for boys and girls. There was neither an effect of age nor sex on SPLmin or SPLmax, ranging between 52.6 and 54.1 dBA and between 86.5 and 82.8 dBA, respectively. Socioeconomic status was not associated with the above-mentioned variables.

CONCLUSION

To our knowledge, this study is the first to present large normative data on the singing voice in childhood and adolescence based on a high number of measurements. In addition, we provide percentile curves for practical application in clinic and vocal pedagogy which may be applied to distinguish between normal and pathological singing voice.

Analyzing Longitudinal Data on Singing Voice Parameters of Boys and Girls Aged 8 to 12.5 and Possible Effects of a Music Pedagogical Intervention

OBJECTIVE

Controlled and randomized study to analyze longitudinal voice data of boys and girls aged 8-12.5, to describe their physiological development and to evaluate the influence of a one-year music pedagogical interventional program focused on the singing voice.

METHODS

Singing voice profiles of 116 children (52 boys, 64 girls) aged 8-12.5 years were collected longitudinally at the beginning and the end of the third school year and the end of the fourth school year. 64 of the 116 children received a music pedagogical program during their third school year (interventional group). Maximum and minimum voice intensity, highest and lowest frequency, maximum phonation time (MPT) and Jitter were investigated.

RESULTS

In two years' time highest frequency increased on average by 100.23 Hz from G1 up to A1 for boys and for girls. Lowest frequency decreased by 18.36Hz from Gis-1 to G-1 (boys: Gis-1-Fis-1; girls: A-1-G-1). There was no clinically relevant development of the intensity parameters for both sexes. However, after the interventional year, minimum voice intensity significantly decreased in the interventional group compared to the control group. The MPT increased by 2.41 seconds from 10.67 seconds up to 13.09 seconds in two years. Here the increase was higher for boys (+3.2 seconds) than for girls (+1.77 seconds). Jitter was found to be 0.84%-1.11%, showing no clinically relevant changes in two years.

CONCLUSION

To the best of our knowledge, for the first time this study presents longitudinal data on singing voice parameters of the voice range profile of boys and girls aged 8-12.5 years. While frequency and intensity parameters develop equally for boys and girls, the MPT is found to develop more distinctly within boys. A music pedagogical intervention of a small extent has a positive effect on the ability to sing as soft as possible.

Cross-Cultural Adaptation and Validation of the Hong Kong-Chinese Version of Children's Voice Handicap Index

OBJECTIVE

This study aimed to cross-culturally adapt and validate a Hong Kong Chinese version of the Children's Voice Handicap Index (CVHI-10(HK)) and to examine its psychometric properties as a measure of quality of life in dysphonic children.

METHOD

The English version of Children's Voice Handicap Index-10 was translated and adapted to Hong Kong Chinese. Content validity was obtained from ratings of an expert panel and other psychometric properties were measured from CVHI-10(HK) questionnaires completed by 63 children (Dysphonic group: n = 28, vocally-healthy Control group: n = 35) aged between eight to 14 years.

RESULTS

CVHI-10(HK) showed good psychometric properties. Internal consistency measured with Cronbach's alpha coefficient was 0.787. It also showed excellent content validity (scale-level content validity indices ≥ 0.90) and good construct validity (between group difference in total CVHI-10(HK) score: t (33.62) = 4.393, P < 0.001, Cohen's d = 1.157). Analysis on criterion validity revealed a significant and moderate correlation between the total CVHI-10(HK) score and auditory-perceptual ratings on overall severity (Pearson's r = 0.505, P < 0.001). Receiver operating characteristic analysis showed an excellent intrinsic accuracy in discriminating the two groups of children (area under the curve = 0.808) and suggested a cutoff score of three would give the optimal sensitivity and specificity combination of the questionnaire.

CONCLUSION

CVHI-10(HK) is a valid and sensitive tool that measures quality of life in dysphonic children. It is the first self-administered questionnaire that is available to the paediatric dysphonic population in Hong Kong. It may also be used as a screening tool to identify dysphonic children and those who are at risk of voice problems in the local context.

Listener Perceptions of Women With Voice Disorders: Vocal Stereotyping and Negative Personality Attribution

PURPOSE

The purpose of the study was to determine if the age and amount of background knowledge of listeners affects perceptual judgments of women with voice disorders.

METHOD

Forty participants in three different age groups (children, young adults, and older adults) rated five female voice samples representing various types of dysphonia. One group of young adults had background knowledge of voice disorders based on a graduate-level course in Voice Disorders. A semantic differential scale was used to rate the speakers on 24 attributes.

RESULTS

Results indicated that age of listeners was not a significant factor, and that listeners' ratings depended on the specific type of dysphonia. No significant differences emerged between the perceptions of individuals with and without background knowledge of voice disorders.

DISCUSSION

This study agrees with the findings of similar research showing that listeners judge speakers with voice disorders more negatively than they do those with normal voices. This is so regardless of the age and background knowledge of the listener.

The Others Are Too Loud! Children's Experiences and Thoughts Related to Voice, Noise, and Communication in Nordic Preschools

BACKGROUND

High noise levels affect hearing, voice use, and communication. Several studies have reported high noise levels in preschools and impaired voice quality in children. Noise and poor listening conditions impair speech comprehension in children more than in adults and even more for children with hearing or language impairment, attention deficits, or another first language.

AIM

The aim of this study was to explore how children in Finland, Sweden, and Iceland describe the preschool environment in relation to noise, voice, and verbal communication; what were their experiences, knowledge and ideas in relation to voice, noise, and communication. Children's awareness of effects of noise, reactions, and coping strategies were also studied. In addition, country and gender differences were analyzed.

METHODS

Eighteen Icelandic, 14 Finnish, and 16 Swedish children were interviewed using a common interview-guide. Swedish and Finnish children were interviewed in focus groups and Icelandic children individually. All interviews were transcribed verbatim and analyzed thematically by the native speaker. The interviews were translated to English to be re-analyzed for inter-judge reliability of identified themes. Inter-judge reliability was calculated using percentage absolute agreement.

RESULTS

The interviews resulted in 1052 utterances, 471 from focus groups, and 581 from individual interviews. Three themes were identified, Experiences, Environment, and Strategies with two to three subcategories. Inter-judge agreement for the themes was excellent, 92-98%. Experiences occurred in 55% of the utterances. The subcategories were bodily and emotional experiences and experiences of hearing and being heard. Environment occurred in 20% of the utterances, with subcategories indoor vs. outdoor and noise. Strategies was found in 15%, with subcategories games and problem oriented actions. The only significant difference between the countries was for the theme Strategies where the Swedish children produced more utterances than the Finnish. No gender differences were found.

CONCLUSION

Children are aware of high noise levels and mainly blame other children for making noise and shouting. They describe reactions and strategies related to noise like impaired communication and effects on hearing but are less aware of effects on voice. Expressed thoughts were similar across countries. No gender differences were found.

Associations of Speaking-Voice Parameters With Personality and Behavior in School-Aged Children

OBJECTIVES

Previous studies suggest a link between voice disorders and personality traits. However, nearly nothing is known about the relationship between personality and voice parameters in healthy children. The present study investigated associations between children's personality and the intensity and frequency of their speaking voice.

STUDY DESIGN

This is a cross-sectional analysis.

METHODS

The study participants included 871 German children aged from 7 to 14 who had not yet experienced voice change in puberty. Within the framework of the LIFE Child study, all participants were asked to perform a speaking-voice task at four different intensity levels (quietest, conversational, presentation, and shouting voice). Associations of fundamental frequency and voice intensity with children's personality and behavioral strengths and difficulties (assessed using parent-reported questionnaires) were estimated using multiple linear regression analyses.

RESULTS

With respect to children's personality, the analyses revealed significant positive associations between speaking-voice intensity and extraversion (eg, for the conversational voice, β = 0.16, P < 0.001) as well as significant negative associations between voice intensity and emotional stability (eg, for the shouting voice, β = -0.15, P = 0.004) and conscientiousness (for the shouting voice, β = -0.10, P = 0.033). Regarding behavioral strengths and difficulties, we observed significant positive associations between voice intensity and peer-relationship problems (eg, for the conversational voice, β = 0.14, P = 0.001) and prosocial behavior (for the conversational voice, β = 0.11, P = 0.015). In contrast, no significant association was found between speaking fundamental frequency and personality or behavioral difficulties/strengths.

CONCLUSIONS

In children, associations exist between a child's speaking-voice intensity and his or her personality, especially extraversion and emotional stability, and behavioral characteristics.

Respiratory Tract Infections and Voice Quality in 4-Year-old Children in the STEPS Study

OBJECTIVES

Health-related factors are part of the multifactorial background of dysphonia in children. Respiratory tract infections affect the same systems and structures that are used for voice production. The purpose of this study was to investigate if the number of respiratory tract infections or the viral etiology were significant predictors for a more hoarse voice quality.

METHODS

The participants were 4-year-old children who participated in the multidisciplinary STEPS study (Steps to the Healthy Development and Well-being of Children) where they were followed up from pregnancy or birth to 4 years of age. Data were collected through questionnaires and a health diary filled in by the parents. Some of the children were followed up more intensively for respiratory tract infections during the first 2 years of life, and nasal swab samples were taken at the onset of respiratory symptoms. Our participants were 489 of these children who had participated in the follow-up for at least 1 year and for whom data on respiratory tract infections and data on voice quality were available.

RESULTS

The number of hospitalizations due to respiratory tract infections was a significant predictor for a more hoarse voice quality. Neither the number of rhinovirus infections nor the number of respiratory syncytial virus infections was statistically significant predictors for a more hoarse voice quality.

CONCLUSIONS

Based on our results, we would suggest including questions on the presence of respiratory tract infections that have led to hospitalization in the pediatric voice anamnesis. Whether the viral etiology of respiratory tract infections is of importance or not requires further research.

Vocal Symptoms and Voice Quality in Children With Allergy and Asthma

OBJECTIVES

The background for dysphonia is multifactorial, and health-related factors have been listed among the factors affecting voice. In previous studies with adult participants, allergy and asthma have been indicated to have a connection to vocal symptoms. With the majority of previous research being studies involving adult participants, it is unclear what the effect of allergy and asthma on children's voices is. The aim of this study was to investigate if allergies and asthma are risk factors for having vocal symptoms.

METHODS

The material was collected through paper questionnaires distributed to the parents of new pediatric patients at an allergy clinic. The participants were 108 children aged 9 months to 17 years and 1 month.

RESULTS

Of the children whose parents had filled in the questions on vocal symptoms, 18.2% (n = 18) had frequently occurring vocal symptoms, which was defined as having two or more vocal symptoms every week or more often. The most common vocal symptoms were throat clearing and coughing. There was a significant connection between inhalant allergy and having frequently occurring vocal symptoms. The connection between cough that lasted for more than 4 weeks and having frequently occurring vocal symptoms was also significant. In this study, we found no significant connection between having an asthma diagnosis and having frequently occurring vocal symptoms.

CONCLUSIONS

Based on the results of this study, voice screening for children with inhalant allergy would be advisable. Prolonged cough should be taken seriously and be treated, as the mechanical trauma caused by cough seems to have a connection to vocal symptoms.

Indoor Air Problems and Hoarseness in Children

OBJECTIVES

A well-functioning voice is becoming increasingly important because voice-demanding professions are increasing. The largest proportion of voice disorders is caused by factors in the environment. Moisture damage is common and can initiate microbial growth and/or diffusion of chemicals from building materials. Indoor air problems due to moisture damage are associated with a number of health symptoms, for example, rhinitis, cough, and asthma symptoms. The purpose of this study was to investigate if children attending a day care center, preschool, or school with indoor air problems due to moisture damage were hoarse more often than the children in a control group.

METHODS

Information was collected through electronic and paper questionnaires from the parents of 6- to 9-year-old children (n = 1857) attending 57 different day care centers, preschools, or schools with or without indoor air problems due to moisture damage.

RESULTS

The results showed a significant correlation between the degree of indoor air problem due to moisture damage and the frequency of hoarseness. Significant predictors for the child being hoarse every week or more often were dry cough, phlegm cough, and nasal congestion.

CONCLUSIONS

The results indicate that these symptoms and exposure to indoor air problems due to moisture damage should be included in voice anamnesis. Furthermore, efforts should be made to remediate indoor air problems due to moisture damage and to treat health symptoms.