Division of Otolaryngology

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Voice and Swallow Clinics, Division of
Otolaryngology Head and Neck Surgery
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Pediatric Voice TherapyWhy, What and How

• Sarah D. Melton, MA, CCC-SLP
• Shannon M. Theis, PhD, CCC-SLP
• Pediatric Voice Clinic / Otolaryngology
• American Family Childrens Hospital
• University of Wisconsin-Madison Medical School

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Voice Problems

• Voice problems can be described as abnormalities
  in
• Quality
• Pitch
• Loudness
• Resonance
• Most common voice quality problem in children
• is dysphonia/hoarseness

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Estimates

• Over 1 million children suffer from dysphonia
  nationwide
• Incidence of voice disorders in school-aged
  children range from 6 to 23

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Voice Disorders

• Changes in structure or function result in voice
  disorders
• Voice is a developmental phenomenon
• Dysphonias originate from many etiologies
• IMPORTANT NOTE Not all children who present with
  dysphonia have nodules

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Problem

• Voice disorders in children have been shown to
  have a negative impact on
• Communicative effectiveness
• Social development
• Scholastic performance
• Self-esteem

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Listeners impressions

• When compared with non-dysphonic children, kids
  with dysphonia are rated more negatively

• dirty
• cruel
• bad
• worthless
• dishonest

• sick
• sad
• unpleasant
• ugly

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Infant versus Adult Larynx

• Infant larynx is NOT a miniature version of an
  adult larynx
• Differences in size, position, layer structure,
  and ratio of cartilaginous to membranous portions

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Indications for Referral

• Referral for a voice evaluation
• (Otolaryngologist Speech Pathologist)
• Persistent hoarse voice
• Progressive hoarse voice
• Any voice change with airway symptoms (stridor or
  audible breathing)
• Voice change associated with aspiration
• Should be pediatric focused and trained in voice

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EvaluationMay involve all or parts of the
following

• History
• Physical Examination
• Indirect laryngoscopy
• Voice evaluation
• Acoustic Aerodynamic assessments
• Radiographic evaluation
• pH probe
• Direct laryngoscopy, bronchoscopy, and
  esophagoscopy
• Diagnosis
• Treatment
• Medical, Surgical, Behavioral

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History

• A complete history is essential
• History of voice problem involves parental input
• Onset of dysphonia in relation to birth
• Surgical history
• Hospitalizations
• Reflux symptoms
• Breathing difficulties/respiratory conditions
• Intermittent or recurrent dysphonia versus
  persistent or progressive dysphonia

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Voice Evaluation

• History can give us clues into diagnosis, but
  visualization of the larynx is crucial for
  accurate diagnosis
• Indirect laryngoscopy is conducted in the clinic
  while awake
• Flexible fiberoptic endoscopy
• Rigid endoscopy
• Direct laryngoscopy is conducted while the child
  is under anesthesia

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Flexible Fiberoptic Endoscopy
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Flexible Fiberoptic Endoscopy
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Flexible Fiberoptic Endoscopy

• Almost any child can be visualized with this
  technique
• Advantages
• Can assess velopharyngeal function, adenoid
  tissue, palatal structure
• Resting breathing connected speech
• Can sometimes assess subglottis
• Disadvantages
• Clarity is often diminished
• Numbing of nares

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Rigid Laryngoscopy
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Rigid Laryngoscopy
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Rigid Laryngoscopy

• Child must be very cooperative
• Advantages
• Increased clarity for assessing erythema,
  vascularity, tissue changes
• Closer view
• Disadvantages
• Difficult to conduct in young children
• Gag reflex
• Cannot assess other structures

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Case

• 8-year-old with a 3-year history of dysphonia
• Voice therapy through school for 3 years
• Prescribed anti-reflux meds with some benefit
• Mother reported that voice fluctuated based on
  use
• No surgical history
• No swallowing problems
• No stridor or breathing difficulties (per parent
  report)
• Some periods of aphonia
• Presented in clinic completely aphonic

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Pediatric Voice Therapy Why bother?

• Lots of kids are hoarse
• Estimates range from 6-23 of school aged
  population
• Shell grow out of it
• He just sounds hoarse benign condition
• Her voice is so sexy and cute!

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Why bother!?!

• Although many boys outgrow nodules, many girls do
  not
• Educational impact
• Social/emotional impact
• Participation in extracurricular activities
• Peds Quality of Life Voice

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Listeners impressions

• When compared with non-dysphonic children, kids
  with dysphonia are rated more negatively

• dirty
• cruel
• bad
• worthless
• dishonest

• sick
• sad
• unpleasant
• ugly

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Pediatric Voice Therapy What

• Uses similar approaches as with adults
• Traditional approach has been hygiene-focused
• Identify, reduce vocal abuse
• Use of charts/worksheets
• Often punitive/reprimanding/restrictive
• Difficult to carry-over to spontaneous
  speechtechnique needs to be addressed

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Pediatric Voice Therapy What

• Hygiene/hydration does have a role
• Breath support (belly breathing)
• Decrease tension / improve VF closure
• Improve resonance
• Vocal Function Exercises (Stemple)
• Lessac-Madsen Resonant Voice Therapy, LMRVT
  (Verdolini)
• Pre-operative Voice Therapy

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Vocal Function Exercises

• Goal Coordination of subsystems of voice
• Respiratory, phonatory, resonatory systems
• All exercises done with forward placement, quiet
  phonation, least amount of effort
• Completed on lip trills and sustained vowels with
  forward tone placement
• Kids often find tracking their practice very
  motivating, challenges them

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Vocal Function Exercises (cont)

• Warm-up
• Lip trill, then nasal /i/ (Think Wicked
  Witch!)
• Quiet, slightly high pitch
• Sustain as long as possible with as little effort
  as possible, as quietly as possible
• Stretching and Contracting
• Lip trill, then forward /u/ or /o/ (Think
  windy or siren)
• Pitch glides from lowest to highest, vice versa
• Direct attention to forward focus vibration
• Quiet, low effort

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Vocal Function Exercises (cont)

• Power exercises
• Lip trill, then forward /u/ or /o/
• From comfortable pitch, ascend one pitch at a
  time for a total of 5 pitches
• With a keyboard, from middle C D E F G
  but can ballpark it
• By the fifth pitch, should feel high and should
  be harder to sustain as long
• Sustain as long as possible with as little effort
  as possible, as quietly as possible
• Cool-down
• Nasal / forward placed ng
• Gentle glide down the scale, complete 3 times
• Quiet, low effort

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Lessac-Madsen Resonant Voice Therapy

• Goal achieve barely abducted, barely adducted
  glottal configuration
• Barely aBducted -gt not pressed -gt decreased
  respiratory drive/effort
• Barely aDducted -gt sharp and complete shut-off of
  flow -gt bigger changes in density of air in sound
  wave -gt sensation of facial vibration

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LMRVT (cont)

• High amplitude but low impact stress
• Strong, functional voice (vs. confidential voice
  therapy)
• Follows principles of motor learning
• Paying attention to effects of a motor activity
  as a target (anterior vibrations)
• Focus on kinesthetic awareness to solidify
  learning

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Pre-Operative Voice Therapy

• For patients undergoing surgery (i.e., cyst
  removal)
• Two to three days complete voice rest
• No whispering, laughing, throat clearing, etc
• Three days gradual reintroduction of voice
• Limit talking to asking/answering questions
• Frequent completion of exercises
• Strict vocal hygiene
• Three days continued reintroduction of voice
• Frequent voice rest, continued use of exercises
• Post-operative voice therapy at one week

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Perceptual Assessment of Improvement

• Overall level of dysphonia
• Roughness, breathiness, strain/back focus
• GRBAS is a good guide, CAPE-V too
• Glottal fry
• Pitch, loudness
• Breath support
• Imperative to comment on this otherwise we
  become technicians
• Monitor/comment on this throughout therapy to
  assess progress

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Pediatric Voice Therapy How???

• Goals are relatively the same from peds to adults
• Considerations for pediatric population
• Abstract concepts
• Importance/motivation/compliance
• Attention span
• Self-monitoring skills
• Some targets are easier for kids than adults!

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The Voice Police -- ???

• Addressed directly in first session, reminders
  and discussion as needed thereafter
• Good for your voice / Not-so-good for your voice
• Hydration water, avoidance of caffeine
• Reflux (if needed--plays a role for many children
  with nodules, even when asymptomatic)
  medication, avoidance of / moderation with
  reflux-associated foods, other precautions
• Good vocal health avoid yelling and screaming,
  periodic voice rest, non-vocal creative/energetic
  activities, resting the body, etc.
• Education rather than admonishment
• -discussion of choices

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Belly Breathing

• Develop initial awareness of breathing at rest
• Childs hand on their belly/chest increases
  awareness which hand is moving?
• Stuffed animals can help awareness too
• Continuum lying, slouching, sitting up
• Bellyballoon
• Pair with voiceless and then voiced sounds to
  reinforce pattern in speech activities

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Resonant Voice

• Begin with lip trills, then humming, sustained
  and in pitch glides
• Focus attention on anterior vibration
• Can use manual palpation of face
• Voice should feel easy, sound clear
• Can be more specific with adults
• Although kids are surprising!
• BTG VIDEO , NNN VIDEO

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Either/or decisions

• Clear vs scratchy
• Front vs back
• (do they feel vibrations?)
• Easy vs tight
• C/F/E VIDEO

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Hierarchy of targets

• Lip trills a good warm-up at any age
• Mmmm
• Sustained, pitch glides
• Mvowels, repeated
• M-initial words, phrases
• Voiced continuants
• Sustained, pitch glides
• Voiced continuant loaded words, phrases
• Functional sentences
• Reading, conversational activities
• M VIDEOS 1 AND 2

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Resonant Voice

• Immediate need for real world applications of
  buzzy voice
• Begin addressing carry-over ASAP
• Family member names, functional sentences,
  embedding targets in session activities
• as you would do with ANY peds speech therapy
• SENTENCE SLOW TO FAST, Z SENTENCE,
• PULL OUT WORD FROM CONVERSATION

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Child as clinician

• Immediately begin training self-judgment skills
• Although, children will require more direct
  feedback than adults (contrary to motor learning
  principles)
• Identification of clinician productions
• Positive/negative practice
• Self-judgments of productions
• Rating scales
• POSITIVE NEGATIVE PRACTICE VIDEO

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Compliance/Motivation

• This is a HUGE issue with kids moreso than
  adults
• Especially for those who have been hoarse since
  birth
• FAMILY compliance/motivation is crucial

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Increasing motivation (and hopefully compliance)

• Physical motivators
• Less tired
• Less pain
• Feels good
• Social/communicative motivators
• Ability to be heard
• Ability to be understood
• Sound like other kids
• Not teased

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Increasing motivation

• The COOL factor
• Princess voice, Superman voice, Motorboats
• I beat you! Competition as motivation
• From time trials to Voice Skee-ball
• Limit parent criticism
• Assure them they dont have to be the Voice
  Police

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Increasing motivation

• Approach from perspective of fun, not punishment
• I love non-stop talkers!!!
• Especially for pre-operative voice therapy
• Voice rest does not equal thumb twiddling
• Find ways to make it special for the child
• Need to be concrete in recommendations
• Functional reminders throughout the day
• Charting home practice
• From Post-it notes to Turkey baster
• FUNCTIONAL VIDEO

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So why bother?

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• He was hoarse 80 of the time and it had
  started to affect his personality. He would have
  regular melt downs after school and would anger
  easily. At the time I didnt associate his
  behavior with his voice problems at all.. In 4th
  5th grade a great deal of the projects involve
  oral presentations He was not audible to the
  kids just a few feet away and didnt volunteer
  for anything that required more than a few word
  answer. Once he realized he wouldnt be called
  on to answer, he gradually started to pay less
  attention and withdraw from regular classroom
  activities. His teacher says now his hand is up
  all the time and he tends to have REALLY LONG
  answers! The reading tests are done orally I
  dont think its any coincidence that now his
  reading test results jumped two levels What Im
  trying to get across is the difference is much
  more than the fact that he can talk now. Hes
  happy and easy going, hes achieving better
  academically, and hes talking NON STOP! Hes
  had so much to say bottled up inside- and its
  all coming out now.