Dysphonic Children Research Articles

Normative Values for the Children Voice Handicap Index-10 (CVHI-10) and for the Children Voice Handicap Index-10 for Parents (CVHI-10-P)

ObjectivesThe objective of this study was to establish normative data and cut-off scores for the Children Voice Handicap Index-10 (CVHI-10) and the Children Voice Handicap Index-10 for Parents (CVHI-10-P) MethodsFor normative data, CVHI-10 and CVHI-10-P questionnaires originally developed in the Italian language were completed by 201 children without dysphonia and with no history of voice disorders, and by one of their parents. The results were analyzed for mean, standard deviation (SD), and standard error of the mean (SEM) for both questionnaires. For cutoff values determination, data from 49 dysphonic children and from one of their parents were also used. This analysis was based on the sensitivity and specificity indicators of the questionnaires using the ‘‘receiver operating characteristic’’ (ROC) curve. ResultsAnalysis of the questionnaires related to healthy children revealed a mean of 0.26 (SD 0.74; SEM 0.06) for CVHI-10 and a mean of 0.15 (SD 0.49; SEM 0.04) for CVHI-10-P for the normative values. ROC curve analysis allowed us to establish the cutoff scores of 2.5 for CVHI-10 and 1.5 for CVHI-10-P. ConclusionsThis study offers normative data for CVHI-10 and CVHI-10-P and provides cutoff values for both questionnaires to distinguish healthy and pathologic responders.

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

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. Observational, prospective, cross-sectional study. 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. 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). 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.

Pediatric Dysphonia: When to Refer.

The reported prevalence of voice disorders in the pediatric population varies widely between studies, ranging from 3.9% to 23%. Despite this, not all children with dysphonia are referred to a voice specialist for further evaluation. The objective of this study is to examine the relationship between dysphonia history, voice assessment, and laryngeal findings to help guide referrals of dysphonic children. A retrospective review was conducted of pediatric patients at a tertiary voice clinic between January 2014 and December 2017. Data including dates of presentation, demographics, co-morbidities, presenting symptoms, laryngeal exam findings, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores, and Pediatric Voice Handicap Index (pVHI) scores were collected and analyzed. Of 475 patients initially identified, 459 met inclusion criteria and were reviewed. In all, 272 (59.3%) were male and 187 (40.7%) were female. Mean age at first presentation was 8.6 years old (range: 2-18). Males were more likely to present at a younger age than females. CAPE-V data were available for 439 patients, and pVHI data were available for 109 patients. The mean CAPE-V Overall Severity score was 38.2. The mean total pVHI score was 25.4. Males had higher CAPE-V Overall Severity (40.0 vs. 35.4), Roughness (32.2 vs. 27.6), and Strain scores (37.2 vs. 32.4) than females. Patient pVHI scores did not differ by gender. In all, 283 patients self-reported a length of symptoms prior to evaluation. Children with a longer duration of symptoms prior to evaluation had higher CAPE-V Overall Severity scores. Diagnoses of vocal fold movement impairment and benign vocal fold lesions that were not nodules were associated with higher average CAPE-V Overall Severity scores. Overall, 310 patients (67.5%) were recommended intervention for their dysphonia. These patients had higher CAPE-V Overall Severity scores than those who were solely recommended observation (42.8 vs. 28.0). Males were more likely than females to present with dysphonia and presented with more severe perceptual dysphonia scores on average. The length of symptoms and certain diagnoses correlated with higher CAPE-V Scores. Referrals to a pediatric voice clinic should be considered in patients with a dysphonia history lasting greater than 3 months and in patients with more severe symptoms.

Knowledge of the Voice in the Teachers' Population and their Ability to Refer Children with Voice Disorders to a Speech-Language Pathologist

The objectives of this study were to investigate (1) the knowledge of primary school teachers regarding voice and voice disorders, (2) the primary school teacher's ability to identify and refer a dysphonic child to a speech-language pathologist (SLP), and (3) potential contributing factors that might affect this ability. Thirty-one primary school teachers (30 women, one man) with a mean age of 33 years (range: 22-57 years; SD: 11.1 years) were included in this study. They filled out an online questionnaire, gathering demographic information, estimations of their knowledge regarding voice and voice disorders, and their ability to refer a dysphonic child to an SLP. Furthermore, they completed an online quiz (maximum score: 9) with basic questions about the voice, vocal health and voice disorders. Most teachers (58.1%) rated their knowledge as basic, 16.1% as adequate and 25.8% as good. One out of four teachers (25.8%) received voice-related information during their education. A substantial part (38.7%) gathered information through other channels, such as voice therapy. Almost all participants (90%) reported to have no or little experience with dysphonic children. Half of them (51.6%) felt unsure about their ability to refer a dysphonic child to an SLP, and 54.8% were willing to attend extra voice workshops. A significant association was found between the estimated knowledge regarding voice (disorders) and attendance of voice therapy (P=0.020). More than half of the teachers who attended voice therapy (57.1%) estimated their voice-related knowledge as good, compared to only 16.7% of the teachers who did not attend voice therapy. Moreover, a significant association was found between the years of teaching experience and the quiz total score (P=0.040). The majority of the teachers with the least teaching experience (57.1%) achieved a score between 4 and 6, whereas the teachers with more experience achieved a score between 7 and 9. This study suggests that the voice-related knowledge of primary school teachers is limited. Consequently, teachers do not feel confident in referring a dysphonic child to an SLP. As teachers can be important sources in indirect assessment of pediatric dysphonia, they need to be well informed and extensively trained in using voice screening protocols. Interdisciplinary cooperation between SLPs and teachers should be optimized to provide the best available care and improve the children's quality of life.

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

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. Observational, prospective, cross-sectional study. 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. 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. 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.

Laryngeal pathologies in dysphonic children with Down Syndrome

IntroductionDown syndrome is the most common chromosomal abnormality and is associated with a higher incidence of congenital heart defects, which often require surgery within the first year of life. Previous studies have found that children with Down syndrome are at higher risk for subglottic stenosis, vocal fold paralysis, and laryngomalacia. The goal of this study is to review children with Down syndrome presenting with dysphonia and to characterize their laryngeal pathologies. MethodsA retrospective review was performed of patients with Down syndrome seen at a tertiary pediatric hospital's department of otolaryngology from Jan. 2007–Jul. 2021 for voice-related concerns. Inclusion criteria included age less than 18 years, diagnosis of Trisomy 21, and complaint of dysphonia. The data extracted included history of dysphonia, co-morbidities, demographic information, age at presentation, perceptual voice assessments, voice quality of life scores, acoustic data, laryngoscopic and/or videostroboscopic exams, and surgical procedures. ResultsTwenty-three total patients met the study criteria. Of these children, 13 (57%) were male and 10 (43%) were female. The mean age at first presentation was 4.08 years (range 12 days–16.3 years). Eleven of the 23 patients presented within the first 12 months of life. Sixteen patients were diagnosed with vocal fold immobility, 13 of which were left-sided unilateral immobility and the remaining 3 were bilateral immobility. 5 patients were diagnosed with vocal fold nodules. 12 children in the immobility group had a history of cardiothoracic surgery at our institution. Only 3 patients had Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) assessments, though all three showed overall dysphonia ratings of severely deviant, with roughness and strain scores being the most severe. DiscussionThe most common etiology of dysphonia in our Down syndrome patient population was vocal fold immobility and hypomobility, as opposed to vocal fold nodules (which is the most common in the general pediatric population). The higher likelihood of cardiac surgery in patients with Trisomy 21 may result in the increased incidence of vocal fold immobility. There should be a low threshold to refer dysphonic patients with Down syndrome for laryngoscopic evaluation, as treatment options may be available.

Telehealth for Treatment of Pediatric Dysphonia

Vocal fold nodules are the most common etiology of chronic dysphonia in the pediatric population. Voice therapy is an effective first line of treatment, with increasing evidence supporting the use of telepractice in speech pathology. Despite this, there is limited data on its effectiveness in the pediatric population. The aim of this retrospective study was to investigate the feasibility and efficacy of telepractice in delivering voice therapy to children diagnosed with vocal fold nodules. A retrospective review was conducted of patients treated with virtual voice therapy from April 2020 to June 2021. Patients were included if diagnosed with vocal fold nodules, 2-18 years of age, and completed therapy in a virtual format. Data includes demographics, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores and pediatric Voice Handicap Index (pVHI) scores. Twenty-three children were included, 17 (74%) male and six (26%) female (with an age range of 2.4-9.9 years at the start of therapy). Prior to treatment, the average CAPE-V Overall Severity score was 37.9 (SD 13.8); the average posttreatment score was 22.4 (SD 10.2). The average pVHI total score prior to treatment was 26.3 (SD 12.1), with an average posttreatment score of 20.2 (SD 11.7). Patients who underwent virtual voice therapy had improved posttreatment CAPE-V severity scores than those prior to treatment (average difference = -15.5 points; 95% CI: -8.3 to -22.7; P < 0.001). An increased number of therapy sessions was associated with both higher initial CAPE-V severity scores (r = 0.72; P < 0.01) and a greater decrease in posttreatment CAPE-V scores (r = -0.55; P < 0.01). Virtual voice therapy may be feasible and efficacious in treating dysphonic children diagnosed with vocal fold nodules. Significant improvements were found in perceptual CAPE-V scores in overall severity; positive changes were also seen in parental measures of quality of life. Delivery of voice therapy in a telehealth format may increase access of care and should be considered as a treatment option.

Intubation-Related Laryngeal Deficiency and Vocal Fold Immobility in Pediatric Premature Patients.

We report a posterior laryngeal rating system and measures of voice disability in pediatric patients undergoing phonosurgery for vocal fold paralysis. Posterior glottic deficiency may account for persistent voice disability. Retrospective Study. Retrospective analyses of 66 subjects with primary unilateral vocal fold paralysis were reviewed for the status of posterior glottis and voice disability (Pediatric Voice Handicap Index [pVHI]). Gestation age (GA), weight, and medical/surgical history were reviewed. The width, length, and depth of the larynx were analyzed to create a reproducible rating scale. Mean GA was 29 weeks, with an intubation history for all subjects, with 90% having a left vocal fold immobility. Cardiac surgery was performed in 92% of subjects. A progressive rating (type 0-3) Benjamin Defect Severity Scale (BDSS) was developed to rate the absence or presence of a posterior abnormality. BDSS-2 and BDSS-3 subjects were more likely to have low birth weight. Extremely preterm GA was more likely to be associated with BDSS-1 (mild) or BDSS-2. History of multiple and prolonged intubations were seen more frequently in BDSS-2 or BDSS-3. Post-op pVHI reduced an average of 15 points for BDSS-0 to BDSS-2, but only 3 points for BDSS-3. Post-op pVHI matched normal values for preintervention dysphonic children. The presence of a persistent breathy voice after intervention for unilateral vocal fold immobility is potentially associated with posterior glottic defects. Low birth weight with multiple/prolonged intubation is more likely to be present with higher-grade BDs, whereas low GA is more likely to be associated with BDSS-1 to BDSS-2. 4 Laryngoscope, 131:2550-2557, 2021.

Barriers to Voice Therapy in Dysphonic Children

The most common etiologies of dysphonia in the pediatric population are vocal fold nodules and muscle tension dysphonia. Vocal therapy is the first line treatment for these disorders in children. Despite this, not all children undergo therapy. The goal of this study is to examine how factors such as patient demographics and parental perceptions differ between children that choose to undergo or not to undergo voice therapy. A retrospective review was conducted of all pediatric patients seen at a tertiary voice clinic between January 2014 and December 2017. Patients were included if diagnosed with vocal fold nodules and/or muscle tension dysphonia. Patients were divided into groups of children that received voice therapy at our institution and those that did not. Data include demographics, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores and pediatric Voice Handicap Index (pVHI) scores. Distance to therapy site was approximated using patient zip codes. Three hundred and forty-six children were included, 224 (65%) boys and 122 (35%) girls. In the 2 years following initial diagnosis, 74 (21%) children participated in voice therapy at our institution. Patients who underwent voice therapy were older than those who did not (mean age: 9.1 [SD 3.5] vs 7.6 [SD 3.8] years; P=0.004). Patients who received voice therapy were more likely to live closer to the therapy site (mean distance: 15.5 [SD 13.0] vs 24.3 [SD 23.9] miles; P< 0.001). Likelihood of receiving voice therapy did not differ by gender or health insurance status (private vs public). Patients who underwent voice therapy had significantly greater CAPE-V Overall Severity scores than those who did not (mean score: 44.6 [SD 19.4] vs 37.4 [SD 18.0]; P = 0.003). Higher CAPE-V Strain scores were associated with increased likelihood of voice therapy. pVHI scores did not differ between the two groups. Older age, shorter distance to therapy site, and increased CAPE-V Overall Severity and Strain scores were associated with higher likelihood of receiving voice therapy. Gender, insurance status, and pVHI scores did not affect likelihood of receiving voice therapy. Patients may primarily consider ease of access and necessity of treatment when considering voice therapy.

Cross-cultural Adaptation and Validation of the Hong Kong-Chinese version of Children's Voice Handicap Index-10 for Parents (CVHI-10-P(HK))

The purpose of this study was to cross-culturally adapt and validate the Hong Kong Chinese version of the Children's Voice Handicap Index-10 for Parents (CVHI-10-P(HK)), a parent-proxied quality of life (QOL) questionnaire that pairs with the Children's Voice Handicap Index-10 (CVHI-10(HK)). The English version of the (CVHI-10-P(HK)) underwent forward-backward translation and pretesting. Content validity was computed from an expert panel rating on relevance and test-retest reliability was obtained from parents and/or guardians of six dysphonic and five vocally-healthy children. Other validity and reliability measures were analyzed from CVHI-10-P(HK) completed by parents and/or guardians of 28 dysphonic and 35 vocally-healthy children who had completed CVHI-10(HK). The CVHI-10-P(HK) demonstrated excellent internal consistency (α = 0.091), excellent content validity (item- and scale-level content validity indices = 1.00), good construct validity (between group difference in total CVHI-10-P(HK) score: t(30.904) = -6.449, P < 0.001, Cohen's d = 1.709) and excellent test-retest reliability (r = 0.966, P < 0.001). Criterion validity analysis showed a moderate correlation between the total CVHI-10-P(HK) score and auditory-perceptual ratings on overall severity (r = 0.515, P < 0.001). Area under the curve of the receiver operating characteristic plot was found to be 0.855. The CVHI-10-P(HK) has excellent intrinsic accuracy. A cutoff of score of four may be adopted for the optimal sensitivity and specificity match. A moderate correlation was found between the total scores of CVHI-10-P(HK) and CVHI-10(HK) (r = 0.684, P < 0.001). The CVHI-10-P(HK) is a valid tool that measures QOL of dysphonic children from the parents' perspective. It is recommended to be used in parallel to the CVHI-10(HK) as part of a comprehensive voice assessment for children in Hong Kong.

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

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. 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. 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. 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.

Polish version of the pediatric Voice Handicap Index (pVHI)

IntroductionThe modern standard of voice diagnostics in both the adult and pediatric populations is based on perceptual, acoustic and videolaryngoscopic assessment, as well as self-assessment of voice quality. Currently, only two tools for assessing the voice in the pediatric population were translated into Polish: pVHI and its abbreviated version - cVHI (Children Voice Handicap Index). Thanks to the use of pVHI, the therapist and the patient, as well as his family and relatives, become aware of what functional zones are disturbed as a result of voice problems. AimThe aim of the study was to analyze various methods of assessing children's voice, including the pVHI voice disability questionnaire in children with various voice disorders. In addition, the authors wanted to develop a classification of the degree of disability of children's voice expressed by the sum of points obtained in pVHI. Material and methodThe study included a group of 89 children aged 5-12. Each child underwent a standard otolaryngological and phoniatric examination procedure with hearing assessment and fiberoscopic laryngeal evaluation. The voice of the dysphonic children was assessed with a spectrogram and the GRBAS scale. The children's guardians completed the Pediatric Voice Handicap Index (pVHI). ResultsPolish children without voice disorders obtained an average of 1.9 points as a total result of the pVHI questionnaire. The results of the questionnaire obtained from children with voice disorders were on average 24.7 (SD 13.9). Total and individual domain scores were significantly higher in children with dysphonia than in asymptomatic children. Children with voice disorders were rated an average of 1.95 (SD 0.6) degree of hoarseness in Yanagihara's scale, and obtained an average overall score of 4.8 on the GRBAS scale (SD 2). A common upward trend in all types of evaluation is evident, along with an increase in the handicap expressed in pVHI score. Statistical analysis showed significant dependence between the overall pVHI score and other voice rating indicators. The result correlated to a moderate degree with the sum of points obtained from GRBAS and the severity of hoarseness assessed subjectively (G) and objectively according to Yanagihara's scale. In addition, weak correlations of the functional part of the questionnaire with the presence of learning problems, and the emotional part with the presence of problems with socialization were noticed. Analyzing the results of the questionnaire depending on the GRBAS results and the Yanagihara scale, a better fit of the exponential trend line than the linear one was observed. The point of inflection of the exponential curve, and thus a significant deterioration in voice assessment indicators, was observed in children who obtained over 32 points, which is 33% of the maximum value that can be obtained from the questionnaire. ConclusionsA new voice assessment tool for the pediatric population has been developed that complements the diagnostic facilities of the otolaryngologist, phoniatrician and speech therapist. Adaptation of the Polish version of the Voice Handicap Index (pVHI) allows the introduction of a new diagnostic indicator into medical and speech therapy practice. The pVHI questionnaire result differentiates children with voice and speech disorders from healthy children. The analysis of children's voice using various methods allows the clinician to further characterize the disturbance of voice quality. It is possible to assess the scale of the severity and type of problem, as well as the spheres of life it concerns most. There is a correlation between the severity of voice disorders and the severity of voice disability expressed in the pVHI question.

Adaptation and validation of the Persian version of pediatric Voice Handicap Index (pVHI)

Background and objectivesThis study aimed to assess the reliability and validity of the Persian version of the Pediatric Voice Handicap Index (pVHI). Materials and methodsThe questionnaire was translated into Persian and then administrated to the parents of 45 dysphonic children and parents of 135 normal children. The content validity of the questionnaire was confirmed by eight speech-language pathologists. Internal consistency and test-retest reliability were measured via Cronbach's alpha and intra-class correlation coefficient, respectively. Independent-samples t-test was used to evaluate the discriminative and clinical validity of Persian pVHI. ResultsCronbach's coefficient values were excellent for the total score (α = 0.94) and physical subcomponent (α = 0.91). Moreover, these corresponding values were satisfactory for functional (α = 0.82) and emotional (α = 0.79) subcomponents. Test-retest reliability for the total score was high in both dysphonic and control groups (intra-class correlation coefficient> 0.92). There were significant differences between the control and dysphonic groups in terms of the total score and all subcomponents scores of Persian pVHI. However, no significant difference was observed in the mean total score of the Persian pVHI between the control and dysphonic group regarding gender (P < 0.001). DiscussionPersian version of pVHI is a valid and reliable tool to evaluate the severity of voice disorder and its negative effects on the daily life of Persian children with voice disorder from the Parents' viewpoint.

Voice Disorders in Children: Experience in the Voice Unit at Universidad Católica Clinical Hospital

Dysphonia in children is a common symptom, its prevalence varies between 6% and 23%. There is a broad differential diagnosis and the recommendation is to evaluate dysphonic children with an adequate laryngeal visualization method to achieve an accurate diagnosis and treatment. To describe the experience in the diagnosis of dysphonia in children in the voice unit at Universidad Católica Clinical Hospital Santiago, Chile. A retrospective chart review was conducted of all new pediatric patients treated in the voice unit at Universidad Católica Clinical Hospital between 2012 and 2019. Demographic data, diagnosis, and in-office laryngoscopies were reviewed. All patients were evaluated by the same work team consisting of two Otolaryngologists specialized in vocal pathology and a speech voice therapist. A total of 126 new pediatric patients between the ages of 0 to 18 years were evaluated in the voice unit at Universidad Católica Clinical Hospital Santiago, Chile. The majority were males (54%) with an average age of 9 years. 40% of the diagnosis corresponded to vocal nodules, 26% to vocal cord cysts, the remaining to a group of less frequent diagnosis. Two different groups were studied, the first group evaluated during the years 2012-2015 with flexible fibre-optic laryngoscopy and rigid videolaryngostroboscopy (VLS); the second group evaluated between the years 2015-2019 with distal chip flexible videolaryngoscopy, distal chip flexible VLS and rigid VLS. In the second group, the diagnosis of vocal nodules decreased, and the diagnosis of vocal cord cysts increased in comparison to the first group. Pediatric patients with dysphonia must be evaluated by a multidisciplinary team of experts and adequate equipment. VLS should be considered the gold standard in the diagnosis of vocal cord pathology in pediatric population.

Pediatric laryngopharyngeal reflux: Perceptual, acoustic, and laryngeal findings

ObjectivesDescribe acoustic and laryngeal findings in pediatric patients with subjective dysphonia attributed to laryngopharyngeal reflux (LPR). Determine the impact of LPR on perceived voice quality using the pediatric Voice Handicap Index (pVHI). Compare these findings with age-matched normative values as well as data on pediatric patients with dysphonia due to other etiologies. MethodsRetrospective case series of pediatric patients (age 2–17 years) evaluated at a specialty pediatric voice clinic at a tertiary care children's hospital from January 1 2007 to December 31 2017 in whom LPR in whom LPR was deemed to be the most significant contributing factor for dysphonia based on physical examination and history. Patients with structural laryngeal abnormalities unrelated to LPR, such as raised lesions, stenosis, papillomatosis, or vocal fold immobility were excluded. Results163 out of 1195 evaluable patients met inclusion criteria. Of these, 87% had pVHI and 83% had acoustic data available from their first appointment for analysis. Mean total pVHI score was 24 (range: 0–81). Perturbation measures were elevated in both females (jitter 1.38%, shimmer 4.16%) and males (jitter 2.01%, shimmer 5.62%). Laryngologic assessment revealed: vocal fold changes including erythema and/or pre-nodules in 72% of patients. Cobblestoning of any portion of the pharynx was present in 67% with hypopharyngeal cobblestoning the most common, present in 64% of patients. ConclusionPediatric patients with clinically diagnosed LPR have pVHI, jitter, and shimmer scores that are comparable to previously reported patients with raised lesions, scar and immobility, and values that are significantly higher than published normative data. Dysphonic children should be assessed for LPR and treated when indicated. Level of evidence4.

Laryngeal Microsurgery for the Treatment of Vocal Nodules and Cysts in Dysphonic Children

Introduction: Vocal nodules and cysts are frequent causes of infantile dysphonia. Vocal therapy is the first treatment. Microsurgery has restricted indications, especially for nodules. Objective: To describe our experience with microsurgery for nodules and cysts in children. Methods: Dysphonic children (aged 4–18 years) with the diagnosis of nodules and vocal cysts were initially selected. Of these children, only those were included who had undergone microsurgery. For nodules and cysts, the microsurgery was indicated in cases of failure of vocal therapy and in cases of voice worsening or doubts about the diagnosis. All children were submitted to auditory perceptual vocal analysis and videolaryngostroboscopy (before and after surgery, after 6 months). Surgical outcomes were: total improvement (disappearance of vocal symptoms and of the laryngeal lesions); partial improvement (partial improvement of symptoms and/or maintenance of lesions); no improvement (maintenance or worsening of the symptoms and/or persistence of the lesions). ­Results: There were 78 children with vocal nodules and 27 children with vocal cysts. Surgery was indicated for 12 children with vocal nodules (15.4%) and 12 children with cysts (44.4%). Total improvement registered for nodules and cysts was 75 and 83.4%, respectively. Partial improvement for both lesions was 25 and 16.6%, respectively. Conclusion: The best outcome for laryngeal microsurgery in dysphonic children was for vocal cysts. So, we encourage laryngologists for this conduct in vocal cysts. The success of microsurgery for vocal nodules was lower, and in these cases voice therapy seems to be the best treatment.

Reliability and validity of The Danish pediatric voice handicap index

BackgroundThe pediatric voice handicap index (pVHI) questionnaire was developed in 2006 to provide parental information regarding the impact of a voice disorder on their child's life. ObjectivesThe aim of this study was to make a Danish version of the original American pVHI and to validate the Danish pVHI by evaluating its internal consistency and reliability. Materials and methodsThe original version of the pVHI was translated into Danish. Nineteen parents of dysphonic children, diagnosed in a tertiary otolaryngology hospital department, and 43 parents of children without known voice disorder (control group) completed the questionnaire. The internal consistency, content validity including comparisons of the scores in the two groups and the test-retest reliability were assessed through statistical analysis. ResultsThe total pVHI scores significantly differed between the group of parents with dysphonic children and the group of parents with children without known voice disorder (p < 0.001). The internal consistency showed an excellent consistency (Chronbach's α > 0.9) of the three subdomains score and the total pVHI score. The test-re-test reliability of the total pVHI score was “strong” with a Pearson's correlation coefficient of 0.97. Conclusions and significanceThe Danish pVHI is a valid and reliable instrument to assess the parents' perception of the impact of a voice disorder on a child's physical, social and emotional well-being.

Formulation of a program for treatment of childhood dysphonia

BackgroundDysphonia is a disorder characterized by change in voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life. Childhood dysphonia has several adverse educational and psychosocial implications. Dysphonic children are not aware or not bothered by their voice disorder. Although dysphonia might, in some cases, improve by itself in adulthood, it can be of important value to treat the dysphonic voice already during childhood.AimThe aim of this study was to adapt and formulate a program of voice intervention for childhood dysphonia and apply it on Egyptian children to explore its effectiveness as a therapeutic tool.Patients and methodsThis study was conducted on 20 children of both sexes attending the Phoniatrics Unit in Alexandria Main University Hospital complaining of dysphonia. The remediation program aims to improve dysphonia in children using a combination of indirect and direct treatment techniques. It is a modification of The Boone Voice Program for Children combined with new technologies such as the voice games by Kay Elementrics. It is designed to provide the clinician with step-by-step procedures and materials to remediate voice disorders in school-aged children. The program was translated to Arabic and a number of modifications were done in order to adapt it to the Egyptian children.ResultsThe study showed effectiveness of the remediation program for childhood dysphonia regarding some of the auditory perceptual assessment and acoustic analysis values. Some of the laryngeal examination findings also showed improvement post-therapy. The study showed significant relation between the children’s age, sex, diagnosis, and some pretherapy and post-therapy findings.ConclusionData from the current study suggests that voice therapy may prove to be a valid alternative to just planned follow-up.

Use of cepstral analysis for differentiating dysphonic from normal voices in children

ObjectivesCepstral measures have mainly been evaluated by studies conducted on dysphonic and healthy adults, and many of these studies have reported the advantages of using cepstral measures for the evaluation of dysphonia however there is a paucity regarding to the cepstral analyses' results in dysphonic children. In this present study, it is hypothesized that cepstral peak prominence (CPP) and some other parameters of cepstral analysis would differ in children with vocal nodules when compared with the same parameters of cepstral analysis of healthy children. MethodsIn this present study, totally 54 children aged between 5 years old to 12 years and 7 months participated. The study group consisted of 20 males and 7 females diagnosed with vocal nodules. The control group consisted of an equal number of age- and gender-matched healthy peers. Analysis of Dysphonia in Speech and Voice software (CSL Model 4500 equipment, Kay Elemetrics Group) was used to gather speech sample recordings according to the Consensus Auditory-Perceptual Evaluation of Voice/Turkish protocol. Cepstral measures of all the six CAPE-V sentences and sustained/a/sample were calculated. CPP, CPP fundamental frequency, CPP standard deviation (CPP SD), Low_high spectral ratio (L/H ratio), L/H ratio standard deviation parameters were taken into account when statistical analyses were completed. In addition to the descriptive statistics of ceptral measures for both groups, the differences between the study and control groups according to the gender were documented. ResultsIt was found that for both genders CPP and CPP SD values were significantly higher for the control group for vowel-weighted sample, all voiced-weighted sample, glottal attack-weighted sample, nasal weighted sample, and voiceless-weighted sample. In the vowel-weighted sample, CPP and CPP SD were significantly higher for the control group in males. In females, a difference was only observed on the CPP parameter for the same sentence. In terms of the CPP value of the sustained phonation sample, a significant difference was only detected for males, whereas no difference was detected for females. ConclusionsIn conclusion, present study found that cepstral analysis can be used to determine the difference between dysphonic and healthy voices of children and indicated that cepstral analysis should be a compulsory component of routine clinical voice evaluation of children. In addition, this present study indicates that of the cepstral analysis of sentences appear to be more sensitive to dysphonia than the analysis of vowel samples. In future studies, normative values of the CAPE-V/Turkish sentences and cutoff values for differentiating dysphonia from normal voice should be evaluated using a larger sample size.

Tempo ideal de vibração sonorizada de língua em crianças disfônicas

Objetivo: verificar o tempo ideal do exercício de vibração sonorizada de língua (EVSL) na voz de crianças disfônicas. Método: participaram vinte e sete crianças, entre 04 e 11 anos, com diagnóstico de nódulo ou cisto de pregas vocais. Dessas crianças, onze fizeram parte do grupo experimental (GE) e 16 do grupo controle (GC). A vogal sustentada /ε/ e a contagem de 1 a 10 foram registradas antes (m0) e após o primeiro (m1), terceiro (m3), quinto (m5) e o sétimo (m7) minuto de execução do EVSL. As gravações foram apresentadas a três fonoaudiólogas, que julgaram se houve modificação da qualidade vocal. Os parâmetros acústicos avaliados na vogal sustentada foram frequência fundamental, jitter, shimmer, glotal to noise excitation (GNE) e ruído. Resultados: na avaliação perceptivo-auditiva, não houve modificações significativas entre os momentos de execução do EVSL. Na análise acústica, observou-se que o parâmetro ruído diminuiu e o parâmetro GNE aumentou após três minutos de realização do exercício no GE, em comparação com o GC. Conclusão: não houve melhora em nenhum dos tempos na avaliação perceptivo-auditiva da voz de crianças disfônicas com o EVSL. A análise acústica indicou melhora da qualidade vocal aos três minutos de execução do exercício.