Accepted Manuscript Title: Pediatrician Approach to Dysphonia Author: Mirabelle Sajisevi MD Seth Cohen MD Eileen Raynor MD PII: DOI: Reference:
S0165-5876(14)00320-6 http://dx.doi.org/doi:10.1016/j.ijporl.2014.05.035 PEDOT 7154
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received date: Revised date: Accepted date:
19-3-2014 22-4-2014 26-5-2014
Please cite this article as: Mirabelle Sajisevi, Seth Cohen, Eileen Raynor, Pediatrician Approach to Dysphonia, International Journal of Pediatric Otorhinolaryngology http://dx.doi.org/10.1016/j.ijporl.2014.05.035 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Pediatrician Approach to Dysphonia Mirabelle Sajisevi, MD1, Seth Cohen, MD1, Eileen Raynor, MD1 1
Division of Otolaryngology – Head and Neck Surgery, Department of Surgery, Duke University Medical
us
cr
Corresponding author: Mirabelle Sajisevi, MD Division of Otolaryngology – Head and Neck Surgery, Department of Surgery Duke University Medical Center DUMC 3805 Durham, North Carolina, 27710, USA Email: [email protected] Phone: 716-380-8148 Fax: 919-613-4581
ip t
Center, Durham, North Carolina, USA
an
NO FINANCIAL DISCLOSURES
Ac ce pt e
d
M
ABSTRACT Objective: The prevalence of voice disorders reaches up to 23.4% in the pediatric population and has a negative impact on quality of life. The objective of this study is to examine how pediatricians assess and manage patients with voice disorders and barriers they face when evaluating patients with dysphonia. Subjects and methods: The study was designed as a cross-sectional survey. Pediatricians who are members of the North Carolina Pediatric Society or Duke University Affiliated Physicians were selected to participate in the study. They were emailed a description of the study with a link to a questionnaire regarding comfort level in recognizing an abnormal voice, how often they assess for dysphonia, barriers to evaluation of voice problems, reasons for referral, and common treatments employed. Results: A total of 1,125 physicians were sent a questionnaire and 72 replied for a response rate of 6.4%. Of those who responded, only 16.7% routinely assess patients for voice problems. The most common reasons for not assessing patients for dysphonia include patients not complaining of voice problems or parents not concerned, and being unsure of the best method or available treatment options. Referrals were most commonly made when speech could not be understood or when the voice problem coincided with other neurological symptoms. Allergy and reflux medications were often trialed prior to referral. The majority of responders felt that voice problems impacted quality of life and 84.7% were interested in more information regarding pediatric voice problems. Conclusion: Pediatricians encounter barriers in the assessment of voice problems in their patients. There is evidence from our study that they have interest in learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders. Key words: dysphonia, pediatric, voice INTRODUCTION The prevalence of voice disorders in the pediatric population ranges from 3.9-23.4% [1-3]. The most affected age range is 8-14 years[1] and occurs more commonly in males compared to females [1, 4, 5]. Voice disorders result from a number of etiologies including vocal cord lesions, vocal misuse or abuse, vocal cord paralysis, and trauma[5, 6]. Dysphonia may negatively effect self-esteem, self-image, and participation in school based activities[7]. Studies have shown that voice disorders adversely impact how affected children are perceived by peers, adolescents, and adults, which can impede socialization [8, 9]. Children with voice disorders have been
Page 1 of 5
Ac ce pt e
d
M
an
us
cr
ip t
shown to demonstrate statistically significant impairment compared to healthy children using the Pediatric Voice-Related Quality of Life Instrument [10]. Due to the high prevalence of voice disorders and the negative consequences, proper diagnosis and treatment is essential. Pediatricians are often the first point of contact for health maintenance and new health problems in children. Therefore, they are in a position to screen patients for disease and can direct their patients to appropriate treatment. Otolaryngologists recognize the importance of pediatricians screening for voice disorders. The clinical practice guidelines published on hoarseness in 2009 include a statement to promote awareness of hoarseness by all clinicians [2]. There are also articles outlining the various pediatric voice disorders and vocal behaviors that warrant referral to an otolaryngologist [5, 6]. It is particularly important for pediatricians to play an active role as children may be unaware or unable to report their own hoarseness[11]. However, it is not known how often pediatricians assess for voice disorders or their level of comfort in recognizing an abnormal voice. The purpose of this study was to examine how pediatricians approach the diagnosis and treatment of patients with dysphonia. We hypothesize that pediatricians do not routinely evaluate their patients for voice problems and face barriers to screening for dysphonia. By understanding these limitations, otolaryngologists can provide outreach and collaborate with pediatricians to enhance the detection and management of patients with voice disorders. METHODS Approval was obtained from the Duke University Medical Center Institutional Review Board. Pediatricians who are members of the North Carolina Pediatric Society or Duke University Affiliated Physicians were selected to participate in the study. The specific role of each member in the health care system is unknown as they likely work in many environments including the emergency room, urgent care facility, and clinic but it is suspected they spend at least a portion of their time in the primary care setting. They were emailed a description of the study with a link to a questionnaire and one subsequent reminder email was sent. The North Carolina Pediatric Society determined it was not feasible to send further reminder emails due to the volume of recipients. The survey to pediatricians included questions regarding comfort level in recognizing an abnormal voice and how much they felt voice problems impacted their patients’ quality of life on a seven point Likert scale. Subjects were asked how often they assess for dysphonia, what barriers they face in evaluation of voice problems, reasons for referral, and common treatments employed. They were also inquired regarding referral patterns based on symptoms. Descriptive statistical analysis was performed based upon the responses from the survey. RESULTS A total of 1,323 physicians were identified and sent a questionnaire. There were 198 invalid email addresses for a total of 1,125 potential participants. A total of 72 replied for a response rate of 6.4%. Of all those who responded, 43.1% were males and 56.9% were females. Only 16.7% routinely assess patients for voice problems while 22.2% never evaluate for dysphonia. Of all the respondents, 6.9% felt very comfortable recognizing an abnormal voice while 1.4% were not comfortable. The mean score was 4.2 on a seven point Likert scale (1 represents “not comfortable” and 7 represents “very comfortable”). The majority felt that voice problems affected quality of life with a mean response of 4.6 on a seven point Likert scale (1 represents “not at all: and 7 represents “very much”). 84.7% of responders were interested in more information regarding pediatric voice problems. The most common reasons for not assessing patients for voice problems include patients not complaining of voice problems or parents not concerned, and being unsure of best method or available treatment options. Other reasons included not feeling comfortable evaluating a patient’s voice or having more pressing issues (Table 1). Most common reasons for referral occurred when the patient’s speech could not be understood or when the voice problem coincided with other neurological symptoms. Other common reasons were associated pain in the neck or throat and symptoms persisting greater than 2 weeks (Table 2). A total of 40% of pediatricians refer patients with voice problems to Otolarygologists, 4.2% to speech pathologists, and 55.6% to both. The decision where to refer patients varied on symptomatology. Problems with articulation, stuttering, and delayed speech prompted referral to speech pathologists in 93.1%, 94.4%, and 76.4% of respondents respectively. Ankyloglossia and hyper/hyponasal speech prompted referral to Otolaryngologists in 79.2% and 62.5% of respondents, respectively.
Page 2 of 5
Ac ce pt e
d
M
an
us
cr
ip t
Of the pediatricians who responded, 47.2% commonly trialed allergy and reflux medications prior to referral. A total of 12.5% gave steroids and 6.9% tried antibiotics while 31.9% referred patients prior to any intervention. DISCUSSION The prevalence of pediatric voice disorders is high ranging from 3.9% - 23.4%[2, 3]. Dysphonia can have a significant impact on children including negative effects on communication, social development, self-esteem, and participation in social environments [8, 12]. Children with common voice disorders demonstrate significant impairment compared to controls measured by the Pediatric Voice-Related Quality of Life Instrument [13]. Furthermore, adult voice disorders are thought to arise during childhood in the majority of cases[14]. Many of the pediatric voice disorders are successfully treated with minimally invasive measures such as optimizing vocal hygiene[6]. Therefore, it is important to identify pediatric dysphonia as it has a high incidence and morbidity and is readily treatable. Currently, it is unknown how pediatricians assess or treat dysphonia in their patients. Our study revealed that over one fifth of pediatricians never evaluate for voice problems. The top reason listed for not evaluating voice problems was that patients do not complain. However, this population may not be aware or able to report their own hoarseness. Therefore, a high number of pediatric patients with voice disorders may be overlooked at the primary care level. It is important for pediatricians to play an active role and inquire specifically about voice problems. There were several barriers limiting pediatricians’ evaluation of dysphonia that were identified in our study. Approximately one third of pediatricians were unsure of the best method of evaluating for dysphonia and almost one fifth were not comfortable evaluating a patient’s voice. One potential way to increase familiarity in recognizing dysphonia would be to include an otolaryngology clinical rotation during pediatric residency. There is a need to enhance the referral patterns of pediatricians. Less than one-third (29.2%) of pediatricians who responded would refer a patient with hoarseness who had a history of cardiothoracic surgery. Due to the location of the recurrent laryngeal nerve, it is at risk during cardiothoracic procedures. In a study by Daya et al., the most frequent etiology of vocal fold immobility was iatrogenic, with the majority of cases occurring as a result of cardiothoracic surgery[15]. In another study, the incidence of vocal fold immobility after cardiothoracic surgery was 8%[16]. These data show that cardiothoracic surgery is a risk factor for vocal fold immobility and consequently hoarseness. Our results also suggest that referrals may not be made for patients who have concerning symptoms. Less than one-half (48.6%) of the respondents indicated that associated symptoms including cough, dysphagia and breathing problems prompted referral. Patients with hoarseness and underlying breathing problems may have recurrent respiratory papillomatosis which is potentially life threatening[17]. Additionally, although rare, malignant tumors of the larynx can occur in children such as rhabdomyosarcoma and squamous cell carcinoma which would present with dysphonia and airway obstruction[18]. This reinforces the necessity for improved education and outreach by otolaryngologists to the primary care community. Our study revealed information regarding treatment practices at the primary care level. Prior to referral to an otolaryngologist, nearly half of pediatricians treated patients with anti-allergy and anti-reflux medications. A total of 12.5% of respondents commonly gave steroids and 6.9% tried antibiotics. These medications have documented side effects and are being prescribed prior to laryngoscopic evaluation, potentially delaying accurate diagnosis and treatment. We recognize the weaknesses present in our study. Pediatricians who were more interested in voice disorders may have been more likely to fill out the questionnaire. Furthermore, there was a small response rate which may decrease the validity of the results and introduce sampling bias. The sample chosen were pediatricians from North Carolina and therefore only include practices in this state which may differ from other regions. The questions are subject to misinterpretations and therefore could lead to inaccurate responses. Despite these limitations, our study provides insight into the evaluation and management of dysphonia by pediatricians and demonstrates a need for education and outreach from otolaryngologists. CONCLUSION Pediatricians encounter barriers in the assessment of voice problems. Those who are uncomfortable evaluating hoarseness may not identify voice problems in their patients and therefore will not refer them to specialists, resulting in delay in diagnosis and treatment. There is evidence from our study that they have interest in
Page 3 of 5
learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders.
Ac ce pt e
d
M
an
us
cr
ip t
References [1] Angelillo, N., et al., Epidemiological study on vocal disorders in paediatric age. J Prev Med Hyg, 2008. 49(1): p. 1-5. [2] Schwartz, S.R., et al., Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg, 2009. 141(3 Suppl 2): p. S1-S31. [3] Carding, P.N., S. Roulstone, and K. Northstone, The prevalence of childhood dysphonia: a crosssectional study. J Voice, 2006. 20(4): p. 623-30. [4] Martins, R.H., et al., Dysphonia in children. J Voice, 2012. 26(5): p. 674 e17-20. [5] Baker, B.M. and P.B. Blackwell, Identification and remediation of pediatric fluency and voice disorders. J Pediatr Health Care, 2004. 18(2): p. 87-94. [6] Faust, R.A., Childhood voice disorders: ambulatory evaluation and operative diagnosis. Clin Pediatr (Phila), 2003. 42(1): p. 1-9. [7] Connor, N.P., et al., Attitudes of children with dysphonia. J Voice, 2008. 22(2): p. 197-209. [8] Lass, N.J., et al., Adolescents' perceptions of normal and voice-disordered children. J Commun Disord, 1991. 24(4): p. 267-74. [9] Ruscello, D.M., N.J. Lass, and J. Podbesek, Listeners' perceptions of normal and voice-disordered children. Folia Phoniatr (Basel), 1988. 40(6): p. 290-6. [10] Merati, A.L., et al., Pediatric Voice-Related Quality of Life: findings in healthy children and in common laryngeal disorders. Ann Otol Rhinol Laryngol, 2008. 117(4): p. 259-62. [11] Sneeuw, K.C., M.A. Sprangers, and N.K. Aaronson, The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease. J Clin Epidemiol, 2002. 55(11): p. 1130-43. [12] Lopes, L.W., et al., Severity of voice disorders in children: correlations between perceptual and acoustic data. J Voice, 2012. 26(6): p. 819 e7-12. [13] McMurray, J.S., Medical and surgical treatment of pediatric dysphonia. Otolaryngol Clin North Am, 2000. 33(5): p. 1111-26. [14] Hirschberg, J., et al., Voice disorders in children. Int J Pediatr Otorhinolaryngol, 1995. 32 Suppl: p. S109-25. [15] Daya, H., et al., Pediatric vocal fold paralysis: a long-term retrospective study. Arch Otolaryngol Head Neck Surg, 2000. 126(1): p. 21-5. [16] Carpes, L.F., et al., Assessment of vocal fold mobility before and after cardiothoracic surgery in children. Arch Otolaryngol Head Neck Surg, 2011. 137(6): p. 571-5. [17] Zacharisen, M.C. and S.F. Conley, Recurrent respiratory papillomatosis in children: masquerader of common respiratory diseases. Pediatrics, 2006. 118(5): p. 1925-31. [18] Olgun, Y., et al., Pediatric laryngeal cancer with 5-year follow up: case report. Int J Pediatr Otorhinolaryngol, 2013. 77(7): p. 1215-8.
Page 4 of 5
ip t
Percentage 65.3% 37.5% 33.3% 25% 20.8% 18.1% 11.1% 4.2% 0%
Ac ce pt e
d
M
Reason Other neurologic symptoms/findings Patient’s speech cannot be understood Associated pain in neck/throat Persistent symptoms > 2 weeks Increased strain or effort to speak Patient has voice breaks or interrupted speech Cough, dysphagia, breathing problems Patient participates in activities with increased voice use History of cardiothoracic surgery History of tobacco exposure
an
Table 2. Reasons for referral to specialist for voice evaluation
us
cr
Reason Patients do not complain about voice Parents not concerned Unsure of best method Unsure of treatment options More pressing issues Not comfortable evaluating a patients voice Not enough time Do not feel voice problems are a priority No local speech pathologists/otolaryngologists Table 1. Reasons that pediatricians do not evaluate patients for voice problems
Percentage 77.8% 72.2% 59.7% 59.7% 56.9% 54.2% 48.6% 40.3% 29.2% 4.2%
Page 5 of 5
S0165-5876(14)00320-6 http://dx.doi.org/doi:10.1016/j.ijporl.2014.05.035 PEDOT 7154
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received date: Revised date: Accepted date:
19-3-2014 22-4-2014 26-5-2014
Please cite this article as: Mirabelle Sajisevi, Seth Cohen, Eileen Raynor, Pediatrician Approach to Dysphonia, International Journal of Pediatric Otorhinolaryngology http://dx.doi.org/10.1016/j.ijporl.2014.05.035 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Pediatrician Approach to Dysphonia Mirabelle Sajisevi, MD1, Seth Cohen, MD1, Eileen Raynor, MD1 1
Division of Otolaryngology – Head and Neck Surgery, Department of Surgery, Duke University Medical
us
cr
Corresponding author: Mirabelle Sajisevi, MD Division of Otolaryngology – Head and Neck Surgery, Department of Surgery Duke University Medical Center DUMC 3805 Durham, North Carolina, 27710, USA Email: [email protected] Phone: 716-380-8148 Fax: 919-613-4581
ip t
Center, Durham, North Carolina, USA
an
NO FINANCIAL DISCLOSURES
Ac ce pt e
d
M
ABSTRACT Objective: The prevalence of voice disorders reaches up to 23.4% in the pediatric population and has a negative impact on quality of life. The objective of this study is to examine how pediatricians assess and manage patients with voice disorders and barriers they face when evaluating patients with dysphonia. Subjects and methods: The study was designed as a cross-sectional survey. Pediatricians who are members of the North Carolina Pediatric Society or Duke University Affiliated Physicians were selected to participate in the study. They were emailed a description of the study with a link to a questionnaire regarding comfort level in recognizing an abnormal voice, how often they assess for dysphonia, barriers to evaluation of voice problems, reasons for referral, and common treatments employed. Results: A total of 1,125 physicians were sent a questionnaire and 72 replied for a response rate of 6.4%. Of those who responded, only 16.7% routinely assess patients for voice problems. The most common reasons for not assessing patients for dysphonia include patients not complaining of voice problems or parents not concerned, and being unsure of the best method or available treatment options. Referrals were most commonly made when speech could not be understood or when the voice problem coincided with other neurological symptoms. Allergy and reflux medications were often trialed prior to referral. The majority of responders felt that voice problems impacted quality of life and 84.7% were interested in more information regarding pediatric voice problems. Conclusion: Pediatricians encounter barriers in the assessment of voice problems in their patients. There is evidence from our study that they have interest in learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders. Key words: dysphonia, pediatric, voice INTRODUCTION The prevalence of voice disorders in the pediatric population ranges from 3.9-23.4% [1-3]. The most affected age range is 8-14 years[1] and occurs more commonly in males compared to females [1, 4, 5]. Voice disorders result from a number of etiologies including vocal cord lesions, vocal misuse or abuse, vocal cord paralysis, and trauma[5, 6]. Dysphonia may negatively effect self-esteem, self-image, and participation in school based activities[7]. Studies have shown that voice disorders adversely impact how affected children are perceived by peers, adolescents, and adults, which can impede socialization [8, 9]. Children with voice disorders have been
Page 1 of 5
Ac ce pt e
d
M
an
us
cr
ip t
shown to demonstrate statistically significant impairment compared to healthy children using the Pediatric Voice-Related Quality of Life Instrument [10]. Due to the high prevalence of voice disorders and the negative consequences, proper diagnosis and treatment is essential. Pediatricians are often the first point of contact for health maintenance and new health problems in children. Therefore, they are in a position to screen patients for disease and can direct their patients to appropriate treatment. Otolaryngologists recognize the importance of pediatricians screening for voice disorders. The clinical practice guidelines published on hoarseness in 2009 include a statement to promote awareness of hoarseness by all clinicians [2]. There are also articles outlining the various pediatric voice disorders and vocal behaviors that warrant referral to an otolaryngologist [5, 6]. It is particularly important for pediatricians to play an active role as children may be unaware or unable to report their own hoarseness[11]. However, it is not known how often pediatricians assess for voice disorders or their level of comfort in recognizing an abnormal voice. The purpose of this study was to examine how pediatricians approach the diagnosis and treatment of patients with dysphonia. We hypothesize that pediatricians do not routinely evaluate their patients for voice problems and face barriers to screening for dysphonia. By understanding these limitations, otolaryngologists can provide outreach and collaborate with pediatricians to enhance the detection and management of patients with voice disorders. METHODS Approval was obtained from the Duke University Medical Center Institutional Review Board. Pediatricians who are members of the North Carolina Pediatric Society or Duke University Affiliated Physicians were selected to participate in the study. The specific role of each member in the health care system is unknown as they likely work in many environments including the emergency room, urgent care facility, and clinic but it is suspected they spend at least a portion of their time in the primary care setting. They were emailed a description of the study with a link to a questionnaire and one subsequent reminder email was sent. The North Carolina Pediatric Society determined it was not feasible to send further reminder emails due to the volume of recipients. The survey to pediatricians included questions regarding comfort level in recognizing an abnormal voice and how much they felt voice problems impacted their patients’ quality of life on a seven point Likert scale. Subjects were asked how often they assess for dysphonia, what barriers they face in evaluation of voice problems, reasons for referral, and common treatments employed. They were also inquired regarding referral patterns based on symptoms. Descriptive statistical analysis was performed based upon the responses from the survey. RESULTS A total of 1,323 physicians were identified and sent a questionnaire. There were 198 invalid email addresses for a total of 1,125 potential participants. A total of 72 replied for a response rate of 6.4%. Of all those who responded, 43.1% were males and 56.9% were females. Only 16.7% routinely assess patients for voice problems while 22.2% never evaluate for dysphonia. Of all the respondents, 6.9% felt very comfortable recognizing an abnormal voice while 1.4% were not comfortable. The mean score was 4.2 on a seven point Likert scale (1 represents “not comfortable” and 7 represents “very comfortable”). The majority felt that voice problems affected quality of life with a mean response of 4.6 on a seven point Likert scale (1 represents “not at all: and 7 represents “very much”). 84.7% of responders were interested in more information regarding pediatric voice problems. The most common reasons for not assessing patients for voice problems include patients not complaining of voice problems or parents not concerned, and being unsure of best method or available treatment options. Other reasons included not feeling comfortable evaluating a patient’s voice or having more pressing issues (Table 1). Most common reasons for referral occurred when the patient’s speech could not be understood or when the voice problem coincided with other neurological symptoms. Other common reasons were associated pain in the neck or throat and symptoms persisting greater than 2 weeks (Table 2). A total of 40% of pediatricians refer patients with voice problems to Otolarygologists, 4.2% to speech pathologists, and 55.6% to both. The decision where to refer patients varied on symptomatology. Problems with articulation, stuttering, and delayed speech prompted referral to speech pathologists in 93.1%, 94.4%, and 76.4% of respondents respectively. Ankyloglossia and hyper/hyponasal speech prompted referral to Otolaryngologists in 79.2% and 62.5% of respondents, respectively.
Page 2 of 5
Ac ce pt e
d
M
an
us
cr
ip t
Of the pediatricians who responded, 47.2% commonly trialed allergy and reflux medications prior to referral. A total of 12.5% gave steroids and 6.9% tried antibiotics while 31.9% referred patients prior to any intervention. DISCUSSION The prevalence of pediatric voice disorders is high ranging from 3.9% - 23.4%[2, 3]. Dysphonia can have a significant impact on children including negative effects on communication, social development, self-esteem, and participation in social environments [8, 12]. Children with common voice disorders demonstrate significant impairment compared to controls measured by the Pediatric Voice-Related Quality of Life Instrument [13]. Furthermore, adult voice disorders are thought to arise during childhood in the majority of cases[14]. Many of the pediatric voice disorders are successfully treated with minimally invasive measures such as optimizing vocal hygiene[6]. Therefore, it is important to identify pediatric dysphonia as it has a high incidence and morbidity and is readily treatable. Currently, it is unknown how pediatricians assess or treat dysphonia in their patients. Our study revealed that over one fifth of pediatricians never evaluate for voice problems. The top reason listed for not evaluating voice problems was that patients do not complain. However, this population may not be aware or able to report their own hoarseness. Therefore, a high number of pediatric patients with voice disorders may be overlooked at the primary care level. It is important for pediatricians to play an active role and inquire specifically about voice problems. There were several barriers limiting pediatricians’ evaluation of dysphonia that were identified in our study. Approximately one third of pediatricians were unsure of the best method of evaluating for dysphonia and almost one fifth were not comfortable evaluating a patient’s voice. One potential way to increase familiarity in recognizing dysphonia would be to include an otolaryngology clinical rotation during pediatric residency. There is a need to enhance the referral patterns of pediatricians. Less than one-third (29.2%) of pediatricians who responded would refer a patient with hoarseness who had a history of cardiothoracic surgery. Due to the location of the recurrent laryngeal nerve, it is at risk during cardiothoracic procedures. In a study by Daya et al., the most frequent etiology of vocal fold immobility was iatrogenic, with the majority of cases occurring as a result of cardiothoracic surgery[15]. In another study, the incidence of vocal fold immobility after cardiothoracic surgery was 8%[16]. These data show that cardiothoracic surgery is a risk factor for vocal fold immobility and consequently hoarseness. Our results also suggest that referrals may not be made for patients who have concerning symptoms. Less than one-half (48.6%) of the respondents indicated that associated symptoms including cough, dysphagia and breathing problems prompted referral. Patients with hoarseness and underlying breathing problems may have recurrent respiratory papillomatosis which is potentially life threatening[17]. Additionally, although rare, malignant tumors of the larynx can occur in children such as rhabdomyosarcoma and squamous cell carcinoma which would present with dysphonia and airway obstruction[18]. This reinforces the necessity for improved education and outreach by otolaryngologists to the primary care community. Our study revealed information regarding treatment practices at the primary care level. Prior to referral to an otolaryngologist, nearly half of pediatricians treated patients with anti-allergy and anti-reflux medications. A total of 12.5% of respondents commonly gave steroids and 6.9% tried antibiotics. These medications have documented side effects and are being prescribed prior to laryngoscopic evaluation, potentially delaying accurate diagnosis and treatment. We recognize the weaknesses present in our study. Pediatricians who were more interested in voice disorders may have been more likely to fill out the questionnaire. Furthermore, there was a small response rate which may decrease the validity of the results and introduce sampling bias. The sample chosen were pediatricians from North Carolina and therefore only include practices in this state which may differ from other regions. The questions are subject to misinterpretations and therefore could lead to inaccurate responses. Despite these limitations, our study provides insight into the evaluation and management of dysphonia by pediatricians and demonstrates a need for education and outreach from otolaryngologists. CONCLUSION Pediatricians encounter barriers in the assessment of voice problems. Those who are uncomfortable evaluating hoarseness may not identify voice problems in their patients and therefore will not refer them to specialists, resulting in delay in diagnosis and treatment. There is evidence from our study that they have interest in
Page 3 of 5
learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders.
Ac ce pt e
d
M
an
us
cr
ip t
References [1] Angelillo, N., et al., Epidemiological study on vocal disorders in paediatric age. J Prev Med Hyg, 2008. 49(1): p. 1-5. [2] Schwartz, S.R., et al., Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg, 2009. 141(3 Suppl 2): p. S1-S31. [3] Carding, P.N., S. Roulstone, and K. Northstone, The prevalence of childhood dysphonia: a crosssectional study. J Voice, 2006. 20(4): p. 623-30. [4] Martins, R.H., et al., Dysphonia in children. J Voice, 2012. 26(5): p. 674 e17-20. [5] Baker, B.M. and P.B. Blackwell, Identification and remediation of pediatric fluency and voice disorders. J Pediatr Health Care, 2004. 18(2): p. 87-94. [6] Faust, R.A., Childhood voice disorders: ambulatory evaluation and operative diagnosis. Clin Pediatr (Phila), 2003. 42(1): p. 1-9. [7] Connor, N.P., et al., Attitudes of children with dysphonia. J Voice, 2008. 22(2): p. 197-209. [8] Lass, N.J., et al., Adolescents' perceptions of normal and voice-disordered children. J Commun Disord, 1991. 24(4): p. 267-74. [9] Ruscello, D.M., N.J. Lass, and J. Podbesek, Listeners' perceptions of normal and voice-disordered children. Folia Phoniatr (Basel), 1988. 40(6): p. 290-6. [10] Merati, A.L., et al., Pediatric Voice-Related Quality of Life: findings in healthy children and in common laryngeal disorders. Ann Otol Rhinol Laryngol, 2008. 117(4): p. 259-62. [11] Sneeuw, K.C., M.A. Sprangers, and N.K. Aaronson, The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease. J Clin Epidemiol, 2002. 55(11): p. 1130-43. [12] Lopes, L.W., et al., Severity of voice disorders in children: correlations between perceptual and acoustic data. J Voice, 2012. 26(6): p. 819 e7-12. [13] McMurray, J.S., Medical and surgical treatment of pediatric dysphonia. Otolaryngol Clin North Am, 2000. 33(5): p. 1111-26. [14] Hirschberg, J., et al., Voice disorders in children. Int J Pediatr Otorhinolaryngol, 1995. 32 Suppl: p. S109-25. [15] Daya, H., et al., Pediatric vocal fold paralysis: a long-term retrospective study. Arch Otolaryngol Head Neck Surg, 2000. 126(1): p. 21-5. [16] Carpes, L.F., et al., Assessment of vocal fold mobility before and after cardiothoracic surgery in children. Arch Otolaryngol Head Neck Surg, 2011. 137(6): p. 571-5. [17] Zacharisen, M.C. and S.F. Conley, Recurrent respiratory papillomatosis in children: masquerader of common respiratory diseases. Pediatrics, 2006. 118(5): p. 1925-31. [18] Olgun, Y., et al., Pediatric laryngeal cancer with 5-year follow up: case report. Int J Pediatr Otorhinolaryngol, 2013. 77(7): p. 1215-8.
Page 4 of 5
ip t
Percentage 65.3% 37.5% 33.3% 25% 20.8% 18.1% 11.1% 4.2% 0%
Ac ce pt e
d
M
Reason Other neurologic symptoms/findings Patient’s speech cannot be understood Associated pain in neck/throat Persistent symptoms > 2 weeks Increased strain or effort to speak Patient has voice breaks or interrupted speech Cough, dysphagia, breathing problems Patient participates in activities with increased voice use History of cardiothoracic surgery History of tobacco exposure
an
Table 2. Reasons for referral to specialist for voice evaluation
us
cr
Reason Patients do not complain about voice Parents not concerned Unsure of best method Unsure of treatment options More pressing issues Not comfortable evaluating a patients voice Not enough time Do not feel voice problems are a priority No local speech pathologists/otolaryngologists Table 1. Reasons that pediatricians do not evaluate patients for voice problems
Percentage 77.8% 72.2% 59.7% 59.7% 56.9% 54.2% 48.6% 40.3% 29.2% 4.2%
Page 5 of 5
