The vocal folds are folds of tissue in the voice box that have a soft and delicate lining on the outside. When speaking or singing, the vocal folds come into contact several hundred times per second to create vibration and the production of voice. Vocal nodules are small benign (non-cancerous) swellings that develop on both vocal folds as a result of injury to the soft tissue. Incorrect use of the voice for prolonged periods of time places stress on the lining and causes this swelling to occur. Vocal nodules are the most common vocal pathology seen in children and are most often diagnosed around the age of 4-8 years. Vocal nodules are more common in children than adults, and are around three times more prevalent in the male population.
What are the signs and symptoms?
The signs and symptoms of vocal nodules in children can vary and may include the following:
- Hoarse or breathy voice quality
- Rough or scratchy voice quality
- Vocal fatigue
- Throat discomfort, pain or tightness
- Neck pain
- Decreased pitch range
Decreased vocal quality is not considered to be part of typical development. Support from a Speech Pathologist is recommended if you have concerns about how your child uses their voice.
What causes vocal nodules?
Vocal nodules are caused by repeated stress and strain on the larynx, also referred to as ‘vocal trauma’. Vocal trauma in children typically results from abusive vocal behaviours, such as the use of a persistently loud and effortful talking voice. Because of the delicate nature of the vocal folds, vocal masses develop easily when the vocal folds are exposed to repeated stress and strain without periods of rest.
A number of factors may contribute to the development of vocal nodules in children:
- Persistently loud talking voice
- Screaming/yelling during outside play
- Use of sound effects, animal noises or voice impersonation in play
- Frequent coughing, sneezing and throat clearing
- Affective disorders such as ADHD and hyerperactivity
- Excessive stress or muscle tension
- Loud and prolonged outbursts of emotion (laughing, crying, shouting)
- Gastric reflux
- Asthma and allergies
How are vocal nodules assessed and diagnosed?
If your child has experienced a hoarse or scratchy voice for over 3 weeks, referral to a Speech Pathologist is recommended. The Speech Pathologist will gather developmental case history information and perform an evaluation of the quality, pitch, volume and duration of voice production. A referral to an Ear, Nose and Throat (ENT) physician will be made if vocal nodules or other voice disorders are suspected. ENT assessment often involves the use of an endoscope to view the vocal folds and identify the presence of any swelling or growths. Voice therapy from a Speech Pathologist will not be recommended until vocal nodules have been properly identified and diagnosed by an ENT.
What treatment is available for vocal nodules?
Medical, surgical and behavioural interventions are available for the treatment of vocal nodules. Surgical intervention involves the removal of nodules and is rarely used for children. Surgical intervention approaches for children will remove the existing growths, but will not treat the cause of the condition or prevent further damage from occurring. Behavioural intervention through voice therapy is therefore the most effective and widely used approach for treating vocal nodules in children.
Voice therapy is delivered by a Speech Pathologist and involves teaching a child about healthy voice production, techniques to improve pitch, loudness and breath support, and strategies to reduce vocally abusive behaviours. Muscle relaxation techniques, vocal hygiene practices (such as hydration), and environmental modifications (such as daily ‘vocal rest’) are often incorporated into Learn & Grow treatment programs. Medical intervention may be recommended to reduce the impact of existing medical conditions on vocal fold health (such as reflux and allergies).