INCIDENCE OF CHRONIC HOARSENESS AMONG SCHOOL-AGE CHILDREN
Ellen-Marie Silverman Marquette University, Milwaukee, Wisconsin
Catherine H. Zimmer University o[ Wisconsin, Milwaukee, Wisconsin
A speech and voice screening of a kindergarten through eighth grade Hebrew day school indicated that: (1) 38 (23.4%) of the 162 children in the school exhibited chronic hoarseness, (2) the incidence was higher in the primary grades, and (3) more boys than girls exhibited the disorder. Vocal nodules were diagnosed in 77.7% of the children examined by otolaryngologists. The findings of this and other recent studies indicate that a large number of school-age children, particularly those in the primary grades, exhibit chronic hoarseness. Furthermore, many such children may be expected to have vocal nodules.
A recent paper by Shearer (1972) suggests that the problem of hoarseness may be the most common childhood voice disorder. Information concerning the actual incidence of this disorder among children, however, appears limited (Baynes, 1966; Pont, 1965). Baynes (1966) reported data on the incidence of chronic hoarseness among a sample of elementary school children from one midwestern school system. He observed that approximately 7% of all children evaluated demonstrated chronic hoarseness, that the incidence was higher in first grade than in either third or sixth grade (the only grades surveyed), and that more boys than girls exhibited the disorder. Pont found that 9.1% of 639 children in kindergarten through eighth grade had hoarse voices. In this paper, some data resulting from a speech and voice screening of a Hebrew day school will be reported that (1) generally support Baynes' and Pont's findings and (2) indicate that the incidence of vocal nodules may be quite high among school-age children.
SCREENING T h e voice screening was conducted by E-MS during the 1972-1973 academic 211
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TABLE 1. T h e number of children enrolled in a Hebrew day school by grade and sex and the percentage of children identfied as chronically hoarse by grade and sex.
Grade Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth
Total
Enrollment Boys
Girls
24 15 31 15 23 19 16 8 10
11 9 15 10 13 10 6 3 5
13 7 16 5 10 9 10 5 5
Chronically Hoarse Children (%) Total Boys Girls 25.0 31.2 25.8 46.0 30.4 10.5 12.5 12=5 0.0
45.5 22.2 33.3 50.0 46.2 10.0 16.6 0.0 0.0
7.6 42.8 18.8 40.0 10.0 22.2 10.0 20.0 0.0
year while she was employed by the school as its first speech pathologist. It was part of a general screening program undertaken to identify children with clinically significant communication problems. A total of 162 children, distributed from kindergarten through eighth grade, were enrolled in the school. T h e enrollment for each grade is presented in Table 1. T h e screening involved obtaining a sample of the conversational speech of each child. Hoarseness was identified by applying the definition of Moore (1971, p 538). When hoarseness was detected, the chronicity of the condition was determined. This was done by asking the children whether their voices sounded different than they ordinarily did and by asking a similar question of their teachers, that is, whether the voices of the children generally sounded hoarse. If either or both were uncertain, or if the two answers were in dis. agreement, a second sample was obtained approximately one month after the first. Chronicity was established if both the child's and the teacher's responses were affirmative or if both samples of the child's voice were judged hoarse by E-MS. Following the screening, the parents of all children judged to have chronically hoarse voices were encouraged to arrange for laryngeal examinations for their children. INCIDENCE
OF H O A R S E N E S S
Thirty-nine children were found to possess hoarse voices. Of these 39 children, 32 were judged to have chronically hoarse voices on the basis of examiner, child, and teacher agreement. T h e remaining seven were scheduled for rechecking to establish chronicity. Six of the seven children were judged to have hoarse voices on reevaluation. Therefore, of the 162 children enrolled in the school, 38 (23.4%) were found to have chronically hoarse voices. Chronic hoarseness was by far the most common voice disorder in this school population, accounting for 84.4% of all voice problems detected. More of the children in the primary grades (kindergarten through third grade) than in the higher grades had hoarse voices (see Table 1). In fact,
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SILVERMAN, ZIMMER. CHILDREN'S CHRONIC HOARSENESS
213
26 (68.4%) of the 38 children with hoarse voices were in the primary grades. The highest incidence by grade occurred in the third grade, in which 46.0% of the children were hoarse. From fourth through eighth grade, the incidence declined substantially, with no cases observed among the eighth graders. Considerably more boys (28.9%) than girls (17.7%) were hoarse. This sex difference was not observed at each grade. It was observed in kindergarten, second, third, fourth, and sixth grade. The difference was slightly greater in the primary grades, where 37.7% of the boys and 21.9% of the girls were hoarse, compared to 21.6% of the boys and 10.3% of the girls in the older grades. The incidence by grade and sex in this school population is similar to that reported by Baynes (1966). In both surveys, the incidence was higher in the primary grades and considerably more boys than girls exhibited the disorder. These findings suggest that chronic hoarseness is more prevalent among younger children and that many children may outgrow it. They further indicate that chronic hoarseness is similar to other communication problems such as stuttering and articulation disorders in the higher incidence among males (Powers, 1957). The percentage of hoarse voices (23.4%) in this population, however, appears strikingly high compared to that reported by Baynes (7%) and by Pont (9.1%). These figures, while differing markedly, nevertheless do indicate that chronic hoarseness may be the most common communication problem among schoolage children, since estimates of the incidence of all communication problems in the population at large range from 4% to 10% (Perkins, 1971). Data are not available to provide a basis for attempting to account for the high incidence observed in this private school. However, it can be conjectured that factors possibly contributing to the development of chronic hoarseness in these children may have included three of the factors identified by Wilson (1972) as contributing factors for the development of hoarseness in children, namely psychological factors, vocal misuse, and upper respiratory infections. The atmosphere of the school was perceived as one of considerable tension by E-MS and by several teachers. High expectations of performance were expressed by both parents and teachers, and a competitive spirit was apparent among the children. The children's vocal productions were observed to be generally loud and strained. Loud voices also were common among the children's vocal models, both parents and teachers. It was noticed, too, that the children who were hoarse tended to have siblings who shared the same vocal characteristic. There is a possibility that the location of the school (near Lake Michigan) was an additional factor contributing to the high incidence of hoarseness. Postnasal drainage induced by the rapid changes in humidity and temperature characteristic of this region could have resulted in irritation of pharyngeal and laryngeal tissues and thus contributed to the development of hoarseness. The fact that the peak incidence was in the primary grades could be interpreted as suggesting vocal misuse and upper respiratory infections as the
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primary contributing factors for the development of hoarse voices. T h e primary grades embrace a period during which children are especially prone to upper respiratory infections. Moreover, younger children are more likely than older children to use their voices in an uninhibited fashion, talking loudly and screaming (Wilson, 1972). INCIDENCE OF VOCAL NODULES
By the close of the school year, 10 of the 38 children judged to have chronically hoarse voices had been seen by otolaryngologists. One child could not be examined because of a hyperactive gag reflex. Of the nine children examined, seven (77.7%) were diagnosed as having bilateral vocal nodules. Five of the seven children were boys. T h e incidence of vocal nodules a m o n g the nine children examined is consistent with Shearer's (1972) report that slightly more than one-half of the children with voice problems referred to a school diagnostic team were found to have vocal nodules. These data support Shearer's (1972) speculation that the incidence of vocal nodules among school-age children may be considerably higher than previous reports (Wilson, 1961) indicated. IMPLICATIONS
T h e findings of this and other recent studies (Baynes, 1966; Shearer, 1972) indicate that a rather large number of school-age children, particularly those in the primary grades, exhibit chronic hoarseness. Furthermore, many such children may be expected to have vocal nodules. It is important, therefore, that clinicians working in the schools identify these children. A case-selection procedure relying solely on referrals from classroom teachers would not be adequate. Teachers without special training in the identification of voice disorders have been shown to be quite poor at identifying children with voice disorders (Wilson, 1972). ACKNOWLEDGMENT
Preparation of this manuscript was partially supported by a Faculty Research Grant from the Marquette University Graduate College. A portion of this paper was presented at the Annual Convention of the American Speech and Hearing Association, Las Vegas (November 1974). Requests for reprints may be addressed to Ellen-Marie Silverman, Communicative Disorders Curriculum, College of Speech, Marquette University, Milwaukee, Wisconsin 53233. REFERENCES
BAYNE$, R., An incident study of chronic hoarseness among children. 1. Speech Hearing Dis., $1, 172-176 (1966). MOORE, G. P., Voice disorders organically based. In L. Travis (Ed.), Handbook o/ Speech Pathology and Audiology. New York: Appleton-Century-Crofts, 535-570 (1971). PE~INS, W., Speech Pathology: An Applied Behavioral Science. St. Louis: C. V. Mosby (1971). PONT, C., Hoarseness in children. W. Mich. Univ. J. Speech Ther., 2, 6-8 (1965).
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SILVERMAN, ZlMMER. CHILDREN'S CHRONIC HOARSENESS
215
POWERS, M., Functional disorders of articulation--symptomatology and etiology. In L. Travis (Ed.), Handbook o/ Speech Pathology. New York: Appleton-Century-Crofts, 707-768 (1957). SHEARER, W., The diagnosis and treatment of voice disorders in school children. ]. Speech Hearing Dis., 37, 215-221 (1972). Wit-sou, D. K., Children with vocal nodules. ]. Speech Hearing Dis., 26, 19-25 (1961). WILSON, D. K., Voice Problems of Children. Baltmore: Williams and Wilkins (1972). Received July 29, 1974. Accepted August 21, 1974.
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Ellen-Marie Silverman Marquette University, Milwaukee, Wisconsin
Catherine H. Zimmer University o[ Wisconsin, Milwaukee, Wisconsin
A speech and voice screening of a kindergarten through eighth grade Hebrew day school indicated that: (1) 38 (23.4%) of the 162 children in the school exhibited chronic hoarseness, (2) the incidence was higher in the primary grades, and (3) more boys than girls exhibited the disorder. Vocal nodules were diagnosed in 77.7% of the children examined by otolaryngologists. The findings of this and other recent studies indicate that a large number of school-age children, particularly those in the primary grades, exhibit chronic hoarseness. Furthermore, many such children may be expected to have vocal nodules.
A recent paper by Shearer (1972) suggests that the problem of hoarseness may be the most common childhood voice disorder. Information concerning the actual incidence of this disorder among children, however, appears limited (Baynes, 1966; Pont, 1965). Baynes (1966) reported data on the incidence of chronic hoarseness among a sample of elementary school children from one midwestern school system. He observed that approximately 7% of all children evaluated demonstrated chronic hoarseness, that the incidence was higher in first grade than in either third or sixth grade (the only grades surveyed), and that more boys than girls exhibited the disorder. Pont found that 9.1% of 639 children in kindergarten through eighth grade had hoarse voices. In this paper, some data resulting from a speech and voice screening of a Hebrew day school will be reported that (1) generally support Baynes' and Pont's findings and (2) indicate that the incidence of vocal nodules may be quite high among school-age children.
SCREENING T h e voice screening was conducted by E-MS during the 1972-1973 academic 211
Downloaded From: https://jshd.pubs.asha.org/ by a Univ of York-England User on 03/22/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx
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TABLE 1. T h e number of children enrolled in a Hebrew day school by grade and sex and the percentage of children identfied as chronically hoarse by grade and sex.
Grade Kindergarten First Second Third Fourth Fifth Sixth Seventh Eighth
Total
Enrollment Boys
Girls
24 15 31 15 23 19 16 8 10
11 9 15 10 13 10 6 3 5
13 7 16 5 10 9 10 5 5
Chronically Hoarse Children (%) Total Boys Girls 25.0 31.2 25.8 46.0 30.4 10.5 12.5 12=5 0.0
45.5 22.2 33.3 50.0 46.2 10.0 16.6 0.0 0.0
7.6 42.8 18.8 40.0 10.0 22.2 10.0 20.0 0.0
year while she was employed by the school as its first speech pathologist. It was part of a general screening program undertaken to identify children with clinically significant communication problems. A total of 162 children, distributed from kindergarten through eighth grade, were enrolled in the school. T h e enrollment for each grade is presented in Table 1. T h e screening involved obtaining a sample of the conversational speech of each child. Hoarseness was identified by applying the definition of Moore (1971, p 538). When hoarseness was detected, the chronicity of the condition was determined. This was done by asking the children whether their voices sounded different than they ordinarily did and by asking a similar question of their teachers, that is, whether the voices of the children generally sounded hoarse. If either or both were uncertain, or if the two answers were in dis. agreement, a second sample was obtained approximately one month after the first. Chronicity was established if both the child's and the teacher's responses were affirmative or if both samples of the child's voice were judged hoarse by E-MS. Following the screening, the parents of all children judged to have chronically hoarse voices were encouraged to arrange for laryngeal examinations for their children. INCIDENCE
OF H O A R S E N E S S
Thirty-nine children were found to possess hoarse voices. Of these 39 children, 32 were judged to have chronically hoarse voices on the basis of examiner, child, and teacher agreement. T h e remaining seven were scheduled for rechecking to establish chronicity. Six of the seven children were judged to have hoarse voices on reevaluation. Therefore, of the 162 children enrolled in the school, 38 (23.4%) were found to have chronically hoarse voices. Chronic hoarseness was by far the most common voice disorder in this school population, accounting for 84.4% of all voice problems detected. More of the children in the primary grades (kindergarten through third grade) than in the higher grades had hoarse voices (see Table 1). In fact,
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SILVERMAN, ZIMMER. CHILDREN'S CHRONIC HOARSENESS
213
26 (68.4%) of the 38 children with hoarse voices were in the primary grades. The highest incidence by grade occurred in the third grade, in which 46.0% of the children were hoarse. From fourth through eighth grade, the incidence declined substantially, with no cases observed among the eighth graders. Considerably more boys (28.9%) than girls (17.7%) were hoarse. This sex difference was not observed at each grade. It was observed in kindergarten, second, third, fourth, and sixth grade. The difference was slightly greater in the primary grades, where 37.7% of the boys and 21.9% of the girls were hoarse, compared to 21.6% of the boys and 10.3% of the girls in the older grades. The incidence by grade and sex in this school population is similar to that reported by Baynes (1966). In both surveys, the incidence was higher in the primary grades and considerably more boys than girls exhibited the disorder. These findings suggest that chronic hoarseness is more prevalent among younger children and that many children may outgrow it. They further indicate that chronic hoarseness is similar to other communication problems such as stuttering and articulation disorders in the higher incidence among males (Powers, 1957). The percentage of hoarse voices (23.4%) in this population, however, appears strikingly high compared to that reported by Baynes (7%) and by Pont (9.1%). These figures, while differing markedly, nevertheless do indicate that chronic hoarseness may be the most common communication problem among schoolage children, since estimates of the incidence of all communication problems in the population at large range from 4% to 10% (Perkins, 1971). Data are not available to provide a basis for attempting to account for the high incidence observed in this private school. However, it can be conjectured that factors possibly contributing to the development of chronic hoarseness in these children may have included three of the factors identified by Wilson (1972) as contributing factors for the development of hoarseness in children, namely psychological factors, vocal misuse, and upper respiratory infections. The atmosphere of the school was perceived as one of considerable tension by E-MS and by several teachers. High expectations of performance were expressed by both parents and teachers, and a competitive spirit was apparent among the children. The children's vocal productions were observed to be generally loud and strained. Loud voices also were common among the children's vocal models, both parents and teachers. It was noticed, too, that the children who were hoarse tended to have siblings who shared the same vocal characteristic. There is a possibility that the location of the school (near Lake Michigan) was an additional factor contributing to the high incidence of hoarseness. Postnasal drainage induced by the rapid changes in humidity and temperature characteristic of this region could have resulted in irritation of pharyngeal and laryngeal tissues and thus contributed to the development of hoarseness. The fact that the peak incidence was in the primary grades could be interpreted as suggesting vocal misuse and upper respiratory infections as the
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primary contributing factors for the development of hoarse voices. T h e primary grades embrace a period during which children are especially prone to upper respiratory infections. Moreover, younger children are more likely than older children to use their voices in an uninhibited fashion, talking loudly and screaming (Wilson, 1972). INCIDENCE OF VOCAL NODULES
By the close of the school year, 10 of the 38 children judged to have chronically hoarse voices had been seen by otolaryngologists. One child could not be examined because of a hyperactive gag reflex. Of the nine children examined, seven (77.7%) were diagnosed as having bilateral vocal nodules. Five of the seven children were boys. T h e incidence of vocal nodules a m o n g the nine children examined is consistent with Shearer's (1972) report that slightly more than one-half of the children with voice problems referred to a school diagnostic team were found to have vocal nodules. These data support Shearer's (1972) speculation that the incidence of vocal nodules among school-age children may be considerably higher than previous reports (Wilson, 1961) indicated. IMPLICATIONS
T h e findings of this and other recent studies (Baynes, 1966; Shearer, 1972) indicate that a rather large number of school-age children, particularly those in the primary grades, exhibit chronic hoarseness. Furthermore, many such children may be expected to have vocal nodules. It is important, therefore, that clinicians working in the schools identify these children. A case-selection procedure relying solely on referrals from classroom teachers would not be adequate. Teachers without special training in the identification of voice disorders have been shown to be quite poor at identifying children with voice disorders (Wilson, 1972). ACKNOWLEDGMENT
Preparation of this manuscript was partially supported by a Faculty Research Grant from the Marquette University Graduate College. A portion of this paper was presented at the Annual Convention of the American Speech and Hearing Association, Las Vegas (November 1974). Requests for reprints may be addressed to Ellen-Marie Silverman, Communicative Disorders Curriculum, College of Speech, Marquette University, Milwaukee, Wisconsin 53233. REFERENCES
BAYNE$, R., An incident study of chronic hoarseness among children. 1. Speech Hearing Dis., $1, 172-176 (1966). MOORE, G. P., Voice disorders organically based. In L. Travis (Ed.), Handbook o/ Speech Pathology and Audiology. New York: Appleton-Century-Crofts, 535-570 (1971). PE~INS, W., Speech Pathology: An Applied Behavioral Science. St. Louis: C. V. Mosby (1971). PONT, C., Hoarseness in children. W. Mich. Univ. J. Speech Ther., 2, 6-8 (1965).
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SILVERMAN, ZlMMER. CHILDREN'S CHRONIC HOARSENESS
215
POWERS, M., Functional disorders of articulation--symptomatology and etiology. In L. Travis (Ed.), Handbook o/ Speech Pathology. New York: Appleton-Century-Crofts, 707-768 (1957). SHEARER, W., The diagnosis and treatment of voice disorders in school children. ]. Speech Hearing Dis., 37, 215-221 (1972). Wit-sou, D. K., Children with vocal nodules. ]. Speech Hearing Dis., 26, 19-25 (1961). WILSON, D. K., Voice Problems of Children. Baltmore: Williams and Wilkins (1972). Received July 29, 1974. Accepted August 21, 1974.
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