The Psychosomatic Aspects of Children With Vocal Nodules Robert J. Toohill, MD
\s=b\ Psychological and emotional aspects of voice disorders have long received attention from otolaryngologists and speech clinicians. The literature contains frequent reports of such problems, but there are few studies on the full importance of these aspects. The cause of vocal nodules in children has been attributed to vocal abuse, and therapy has consisted of the elimination of this abuse. Reports of long-term followup are few, lending suspicion to both the proposed causes and the therapeutic ap-
proaches.
Seventy-seven prepuberal
children with vocal nodules are studied from the social,
The
child with vocal nodules pre¬
perennial management problem for the otolaryngologist and the speech clinician. It was estimated by the American Speech and Hearing sents
a
Association in 1959 that 5% of all schoolchildren had speech problems of such seriousness that their educa¬ tional, social, and emotional adjust¬ ment was affected.1 Voice deviations found in mass screening programs would indicate that this estimate of incidence is too low.2-4 Senturia and Wilson4 stated that 3% would be a more appropriate estimation for voice disorders that cause a communication for publication May 16, 1975. From the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee. Reprint requests to 5757 W Oklahoma Ave, Milwaukee, WI 53219 (Dr Toohill).
Accepted
medical, and physical aspects. The incidence of vocal nodules approaches 1% of all children. Boys predominate this amount by ratios greater than 3:1, with incidence peaks between ages 5 and 10. Conventional modes of therapy have been unsuccessful because of the lack of recognition of psychosomatic factors. New approaches for therapy are sug-
gested including parental involvement, counseling, group therapy, and drug therapy. Though emotional problems may persist, the somatic aspect of this disease
disappears at puberty. (Arch Otolaryngol 101:591-595, 1975)
handicap. The number of children who actually have vocal nodules is un¬ known, but would appear to approach or
exceed 1% of all children.
REVIEW OF THE LITERATURE
Emotional factors of this disorder in children were suggested by White5 when he stressed that all changes in the voices of children are not to be classified as physiological changes. He thought that the psyche of a child was at stake when voice problems were not thoroughly investigated. Lore," in 1950, noted that one of the confusing aspects surrounding the problem of hoarseness in children was the cause of the condition. He studied 19 pa¬ tients and noted that all either had a history of infection in the respiratory tract or lived in an environment con-
ducive to overuse of the voice. Arnold7 stated that screaming chil¬ dren represented a case of tissue re¬ action to mechanical trauma. This has become known as vocal abuse or mis¬ use, and is widely accepted as the prime cause of vocal nodules in chil¬ dren. Senturia and Wilson4 amplified this concept by stating that vocal abuse was precipitated in children largely as a result of mucopurulent secretions in the nasopharynx due to chronic suppurative or allergic rhinosinusitis. With acceptance of vocal abuse as the cause and the therapeutic ap¬ proach of nonsurgical intervention, the speech clinician inherited a prom¬ inent role in the treatment of chil¬ dren with vocal nodules. Wilson" emphasized an elimination or modi¬ fication of chronic vocal abuse. His techniques, which are a model for all speech clinicians, consist of the imple¬ mentation of a variety of rules that attempt to change the habitual pat¬ tern of laryngeal dysfunction in the child. Many isolated case reports indi¬ cate the success of these methods, but large series are infrequent. Brodnitz and Froeschels" reported successful rehabilitation in two chil¬ dren with habitual dysphonia by use of the chewing method, which is based on the relationship between chewing and vocal functions. Later, in evaluating patients undergoing vo-
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cal that
rehabilitation, Brodnitz noted they invariably were victims of
deep emotional disturbances.10 His 1963 report specifically evaluated 29 children, 20 of whom were treated with speech therapy.11 Nine had good results, seven were somewhat im¬ proved, and four were considered un¬
successful. Four were rehabilitated when recurrence was noted after sur¬ gical removal of the nodules. In 1969, Böhme and Rosse,1- being dissatisfied with only 32 successful rehabilitations in 72 patients with vocal nodules, rec¬ ommended drug therapy that utilized cortisone derivatives and insulin
preparations.
There are several studies of emo¬ tional problems in children with speech and voice deviations. Nemec11 was one of the first to present objec¬ tive evidence when he found that chil¬ dren with hyperkinetic dysphonia were more aggressive. He noted they were more immature and less able to handle stressful situations. Sedlackova,14 in 1960, was the first to state that voice disorders in children were symptoms of anxiety. She believed that this was a reaction to social pres¬ sures and an inherited temperamen¬ tal personality. Mosby,15 in 1967, stud¬ ied 25 children-16 with vocal nodules and nine with hoarse, husky voices. She utilized a battery of psychological tests, and results suggested a neu¬ rotic personality with major conflicts,
over-repressed aggression, inadequa¬ cy feelings, poor relationships with parents, and severe dependency needs. Wilson and Lamb,16 in a study of 12
children with vocal nodules and 12 children who served as controls, con¬ cluded that personality types vary from severely aggressive, out of con¬ trol, to the extremely passive overcontrolled adjustment of aggression. Statistical confirmation of increased anxiety was recorded by Marks et al,17 who utilized the junior form of the Eysenck Personality Inventory (EPI) in a study of 11 children with vocal nodules and 11 control patients. Psychiatric therapy has given lim¬
ited, but, nevertheless, important
re¬
sults. In 1960, Withers and Dawson1"
specifically emphasized therapy that dealt with the psychosomatic aspect. They obtained excellent rehabilita-
tion following psychiatric evaluation and treatment of two children with vocal nodules. Mosby19 treated four boys with voice deviancy by a psycho¬ analytic method of the Rorschach In¬ dex of Repressive Style and obtained excellent clinical results. Connelly et al20 reported an innovative technique that used group therapy for 16 chil¬ dren with vocal nodules. This tech¬ nique appears to have substantial merit, since after only six weeks of therapy, seven children were entirely free of nodules, and the remaining nine showed noticeable voice im¬ provement. The authors specifically emphasized parental participation in all aspects of the program. Greene21 particularly stresses the need for assessment of the home background when therapy is under¬ taken. She further notes that anxiety and stress within the family or at school contribute to the expression of vocal abuse in the child with nodules, and this must be alleviated if therapy is to be successful. Renfrew22 con¬ cludes that increased anxiety is the consistent factor in children with this disorder. I review the social and medical as¬ pects of a group of children with vocal nodules, analyze the various forms of therapy utilized for the group, and describe the results of long-term fol¬
low-up.
METHODS
Seventy-seven
children with vocal nod¬ were included in the study. Children with other laryngeal dis¬ orders were not included. A complete social and medical history was obtained for each
ules, all prepuberal,
patient, including
age, sex,
sibling rank,
and onset of symptoms. Complete otolaryngologic examinations were done on all patients. Mirror laryngoscopy was success¬ ful in 75 of the children. It was not always successful on the first examination, but with patience and proper preparation it could invariably be accomplished on the second or third visit. Direct laryngoscopy was used on two occasions to confirm the impression from an inadequate mirror ex¬ amination. An audiogram was performed on each patient. Therapy was divided into four cate¬ gories: (1) school therapy, in which the pri¬ mary form of therapy given to the child was by the school speech therapist; (2) pro¬ fessional therapy, in which therapy was
given by a professional speech therapist or pathologist in a medical center or hospital; (3) parental involvement and counseling, including psychiatric help; and (4) those who received no specific therapy. A patient was
classified
tion
was
cured if vocal rehabilita¬ This included an ab¬ sence of hoarseness or raspiness, normal pitch, good quality, and a larynx that appeared to be normal. Improvement was recorded if there was a decrease in the de¬ gree of hoarseness or raspiness of voice, a diminution in nodule size, and progress in the elimination of vocal abuse. Patients were considered unimproved if they re¬ mained hoarse or raspy in voice quality, and if there was no improvement in their ability to cope with vocal abuse. as
complete.
SOCIAL AND MEDICAL FINDINGS The Figure illustrates the age of incidence for both boys and girls. Two factors are noteworthy. Boys pre¬ dominate by greater than 3:1, and the peak age of incidence is between the ages of 5 and 10. Girls tend to develop vocal nodules slightly earlier than boys. Of the 77 children, one was an only child. Thirteen were the oldest in the family, and 63 had older brothers or sisters, or both. The sources of referral were as fol¬ lows: pediatricians referred 22 of the children; school speech therapists, 21; parents, 4; other sources (including family physicians, allergists, school physicians, and teachers), 12 children. For six children, the source of referral is unknown. Twelve children were noted to be hoarse and to have vocal nodules when they were being exam¬ ined for other problems. Parents were asked to describe the child's person¬ ality and vocal habits. Sixty-two were described by the parents as scream¬ ers, incessant talkers, or loud talk¬ ers. Sixty-six were said to have one or more of the following personality traits: aggressive, hyperactive, ner¬
tense, frustrated, or emotionally disturbed. Attempts were consist¬
vous,
ently made to seek this informa¬ tion from parents without suggestion from the interviewer. The initial symptom was a raspy or hoarse voice that varied in degree. Many parents described this condition as mild, and described the voice quality as raspy rather than hoarse. Sixty-five pa¬ tients initially had these two com¬ plaints. Of the 12 patients who had
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Table 1.—77 Patients With Vocal Nodules
Type of Disorder* Free of associated disorders
No.
Associated disorders Adenoiditis Chronic otitis media Tonsillitis
31 17 16 14 6 3
Allergy
Adenoid hypertrophy Deviated nasal septum Severe prematurity Speech defects Articulation
Velopharyngeal insufficiency
E
46
1
1 10 6
4
3
6
7
Age at Onset of Disease -· Boys ·
Repaired cleft palate
Submucous cleft Following adeno-
tonsillectomy
Stuttering
5
Girls ·-· 1
* While the number of children with asso¬ ciated disorders was only 31, many children had more than one concomitant disorder.
initially been examined for other problems, ten had symptoms related
or chronic otitis media, adenoiditis, or tonsillitis. The dura¬ tion of symptoms varied, with some having the condition for only one month and others having the condi¬ tion since infancy. Most patients had symptoms for 3 to 12 months. In only three patients could abrupt circum¬
to recurrent
stances be related to the onset of symptoms. These three patients were ages 9,11, and 12, and they were each participating in a group activity. The 9-year-old boy abused his voice while being a quarterback for a football team. The 11-year-old boy noted hoarseness after singing, and the 12year-old girl strained her voice after intense playacting. The onset of symptoms in the re¬
mainder was gradual. Many parents noted more pronounced hoarseness in the spring months of April through June. No parents could recall a defi¬ nite attack of laryngitis as the precip¬ itating factor, and very few could as¬ sociate the hoarseness with upperrespiratory tract infections. Group activity would frequently cause a deterioration of voice. Quality would
Boys represented 71.1 % of affected children. Of total of 60 boys, peak age of incidence was between ages 7 and 10 years (50.9%). Girls represented 28.3% of patients. Peak age of incidence for girls was between 5 and 7 years (70.6%). Peak age of incidence for all children was between 5 and 10 years (84.4%). be
good in the morning, but by evening the child was hoarse, whis¬ pering or had severe "breaking of the voice." Table 1 notes other
previous, con¬ subsequent diseases of the patients. Thirty-one had other
comitant,
or
diseases that were of a chronic nature and that were important during the evaluation and treatment. Many had two or more disorders, but the re¬ maining 46 had no other disorders. Thirteen patients had both chronic otitis media and adenoiditis, and nine patients had a conglomerate of chronic otitis media, adenoiditis, and tonsillitis. These, indeed, were the most frequent concomitant diseases. Six patients were allergic, and six had speech articulation defects. No patient had a severe general physical illness or an endocrine or thyroid disease. Seventy-six of the 77 patients in this series had bilateral vocal nodules. The one exception was the 12-yearold girl who was participating in a play and developed a unilateral vocal nodule. Tension in the sternocleidomastoid and strap muscles, and a pal¬ pable increase in rigidity of the
was frequently noted. Pa¬ tients with otitis media had a mild conductive hearing loss, but no severe sensorineural loss was noted.
tongue
RESULTS OF THERAPY
The primary form of therapy in 33 patients was administered by school speech therapists (Table 2). No treat¬ ment was given to 19 children. Pro¬ fessional speech therapy was em¬ ployed in 13 patients. Twelve were treated only by means of parental in¬ volvement and counseling with psy¬ chological help, particularly from the social worker. Ten of 12 patients in
this group were either cured or im¬ proved and the other two were un¬ available for follow-up. The recovery rate did not vary for the three meth¬ ods of treatment, and it compares fa¬ vorably with those who received no treatment. When all forms of therapy were analyzed, 58.5% of the patients were either cured or improved. One third showed no improvement. Fourteen (28%) of the patients who are still prepuberal have recovered with the prescribed therapy. Fifty pa¬ tients (72%) have persistent nodules. The six patients who are now post-
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puberal have all recovered. Only two of the 77 patients had lar¬
yngoscopy and removal of nodules. One patient had removal after speech therapy, and he had a recurrence of nodules two months postoperatively. The second patient had remarkable improvement due to speech therapy, but hoarseness persisted because the nodule on the right true vocal cord had become slightly larger and poly¬ poid. These nodules were removed by microlaryngoscopy and the patient's rehabilitation was complete. Three other patients who appear to have had good results from therapy are being observed, and may require sur¬ gical removal since puberty is at least four years away. Nine patients are of special inter¬ est, eight of whom have persistent nodules, and one of whom was un¬ available for follow-up. They either had a previous history of, or had psy¬ chological deviations. This figure rep¬ resents 12% of the patients with vocal nodules. The pediatrician, speech pa¬ thologist, social worker, and psycholo¬ gist were helpful in identifying these
patients. Methylphenidate (Ritalin)
hydrochloride was successfully used in two patients. Another patient,
whose father had died,
by
an
understanding
assisted mother who was
used the services of a psychiatric social worker. The fourth patient's psychological problem was of such severity that the parents accepted psychiatric help. There are four other children in this group, and the par¬ ents have been counseled but have not followed through with further psychiatric consultation or therapy. COMMENT In assessing this report and those from the literature, it is interesting to note the sex and age of incidence of children with vocal nodules.4·12·23 The natural phenomenon of aggres¬ siveness becomes prominent in the transition period between the passive dependence of infancy and the inde¬ pendence of childhood. Boys play more aggressive roles in social ex¬ change than girls. Environmental in¬ fluences do not completely account for this sex difference. This common mode of behavior is more readily ap-
Table 2.—Results of Treatment Parental Results of Cured
Therapy
Improved Unimproved Unavailable for follow-up Total
School
No
Counseling Therapy
TO" Tí
Professional 3 4
12
ß"
Ö
4 3 7
0 33
0 13
2 12
5 19
parent in emotionally disturbed chil¬ dren, especially boys, during their preschool and early school years.24
Relating to other speech problems, the predominance of boys in patients with vocal nodules would correspond very favorably with the findings of Morley2·'1 in patients with other speech defects. He noted that males pre¬ dominated at a ratio of 3:1 in defects of articulation, and at a ratio of 2:1 in defects related to stammering. There is also a predominance of boys in chil¬ dren with minimal brain dysfunction who are hyperactive, overactive, or hyperkinetic.26 These terms are often used in describing children with vocal nodules. The development of vocal nodules corresponds to the age at which chil¬ dren enter group activities. The prob¬ lem is frequently not apparent until the child enters school and has to cope with groups on a regular basis. Fam¬ ily position also seems to be of impor¬ tance. Morley2"' has noted that defects of articulation and stammering are substantially higher in children who were not the firstborn. This is also true in children with vocal nodules. When related to the competitive at¬ mosphere sometimes created by older children in the family, this finding should be considered to be important in children with vocal nodules. Other diseases associated with vo¬ cal nodules appear to have aggravat¬ ing influences. The finding of otitis media is considered to be important. Associated conductive hearing loss plays an important role in vocal¬ ization of the patient. In my study, three of the six patients with allergic problems were noted to have aggra¬ vation and increased symptoms of hoarseness during the highly allergic seasons of the year. The anxiety of the patients with an articulation de¬ fect, when exposed to their peer
3 7
Totals, (%) 20 (26.0) 25 (32.5) 25 (32.5) 7(9.0) 77(100)
promotes diminished quality of voice. This was likewise true in the three patients in this series who had velopharyngeal incompetence, emphasizing the high incidence of vocal nodules in children with palatal defects.27 A correlation between the presence of associated diseases and the onset of vocal nodules was not substan¬ tiated in this study. Some children who were seen on repeated visits had findings of mild rhinitis, nasophargroups,
yngitis, or pharyngitis. Suggestions of hypopharyngitis with inflammation of the arytenoids or laryngitis were quite rare.4 The finding of bilateral nodules in 76 patients is high when compared to previous studies,4·28 but it compares favorably with the observations of
Böhme and Rosse.12 One nodule is fre¬ quently larger than the other, and this discrepancy accounts for the fact that only the more prominent nodule is noted. This factor, along with tech¬ nical difficulty in visualizing the child's larynx, could account for the reports of unilateral nodules. Re¬ peated observation and use of microlaryngoscopy reveals that the nodules are invariably bilateral. The most common site of occur¬ rence, as noted by Arnold,7 and pres¬ ent in all cases, was centered at the midpoint of the membranous cord. Of those that have been palpated, all are soft and boggy, and, despite the ap¬ pearance of a more mature nodule, it is rare to find the fibrous, varicose, hyalinized, or polypoid nodules in chil¬ dren. The histologie features have been well described, and indicate an edema of the Rienke layer, with in¬ creased vascularity isolated to the site of occurrence.29 Results of present methods of ther¬ apy cannot be considered successful, especially when compared with the
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progress of children receiving no treatment whatsoever. Proper em¬ phasis should be given to the psycho¬ somatic aspect.1'17 If a mild problem exists, and parents rapidly develop insight into the probable causal as¬ pects, rehabilitation may be well un¬ derway and successful. Parental in¬ volvement, counseling, and group therapy will suffice in the majority of cases.20 The more difficult cases re¬ quire assistance from the speech clini¬
cian, social worker, and possibly the
psychologist or psychiatrist, as em¬ phasized in 12% of the patients in this study. The association of minimal
and other central disorders must be investi¬ gated further. The presence of these associations probably accounts for the efficacy of methylphehidate hydro¬ chloride in selected cases. The otolaryngologist must assume the logical position of control, coordination, and observation of the therapeutic pro¬ brain
dysfunction
nervous
the emotionally over-responsive child, and serve only to add to the anxiety that already exists. Surgical removal is rarely indi¬ cated, and this fact has been well recorded by Arnold7 and Strong and Vaughan.29 The child who has under¬
by
gram.
gone successful vocal and personality rehabilitation may have persistent vocal nodules. The advent of micro¬
Although still advocated, voice rest for extended periods of time is impos¬ sible to achieve in a child.30 Conven¬ tional, rigid-rule enforcement by the speech clinician is fruitless. These two forms of therapy cannot be tolerated
Speech therapy data were acquired with the assistance of Mary J. Marks, MS, and Mary K. Galindo, MS.
scopic techniques has made removal a precise and non-traumatizing event.
References 1. Incidence of serious speech problems in school-age children in the United States. J Am Speech Hear Assoc 1:138, 1959. 2. Baynes RA: Incidence study of chronic hoarseness among children. J Speech Hear Dis-
ord 31:172-175, 1966. 3. Nowak VR, Vollbrecht A: Uber die haufigkeit von stimm-und sprachstorungen bei schulanfangern. Dtsch Gesundheitsw 21:654-658, 1966. 4. Senturia BH, Wilson FB: Otolaryngologic findings in children with voice deviations. Ann Otol Rhinol Laryngol 77:1027-1041, 1968. 5. White FW: Some causes of hoarseness in children. Ann Otol Rhinol Laryngol 55:537-542, 1946. 6. Lor\l=e'\JM Jr: Hoarseness in children. Arch Otolaryngol 51:814-825, 1950. 7. Arnold GE: Vocal nodules and polyps: Laryngeal tissue reaction to habitual hyperkinetic dysphonia. J Speech Hear Disord 27:205-217, 1962. 8. Wilson DK: Voice Problems of Children, Baltimore, Williams & Wilkins Co, 1972, pp 13-52, 119-155. 9. Brodnitz FS, Froeschels E: Treatment of nodules of vocal cords by chewing method. Arch Otolaryngol 59:560-565, 1954. 10. Brodnitz FS: Post-operative vocal rehabilitation in benign lesions of the vocal cords. Folia Phoniatr 7:193-200, 1955. 11. Brodnitz FS: Goals, results and limitations of vocal rehabilitation. Arch Otolaryngol 77:148\x=req-\ 156, 1963.
12. Bohme G, Rosse E: Zur haufigkeit altersverteilung therapie und prognose von stimmlippenknotchen. Folia Phoniatr 21:121-128, 1969. 13. Nemec J: The motivation background of hyperkinetic dysphonia in children: A contribution to psychologic research in phoniatry. Logos
4:28-31, 1961.
14. Sedlackova E: Les dysphonies hypercinetiques des enfants causees par surmenage vocal. Folia Phoniatr 12:48-60, 1960. 15. Mosby D: Predominant personality characteristics of twenty-five children with voice disorders. Read before the American Speech and Hearing Association Convention, Chicago, 1967. 16. Wilson FB, Lamb MM: Comparison of personality characteristics of children with and without vocal nodules on Rorschach protocol interpretation. Read before Regional Conference of American Speech and Hearing Association, Atlanta, 1973. 17. Marks MJ, Galindo MK, Toohill RJ: A psychological survey of children with vocal nodules. J Commun Disord, to be published. 18. Withers BT, Dawson MH: Psychological aspects: Treatment of vocal nodule case. Tex Med
56:43-46, 1960.
19. Mosby DP: Appraising psychotherapeutic change in voice deviant children with the Rorschach Index of Repressive Style. Percept Mot Skills 34:701-702, 1972. 20. Connelly MK, Wilson FB, Leeper HA: A group voice therapy technique for decreasing vocal abuse in children with vocal nodules.
J
Speech
Hear Assoc 3:7-18, 1970. 21. Green MC: The Voice and its
Disorders, ed 3. Philadelphia, JB Lippincott Co, 1972, pp 126\x=req-\ 129. 22. Renfrew CE: Speech Disorders in Children, ed 1. New York, Pergamon Press Inc, 1972, pp 52-54. 23. Heaver L: Psychiatric observations on the personality structure of patients with habitual dysphonia. Logos 1:21-26, 1958. 24. Bakwin H, Bakwin RM: Behavior Disorders in Children, ed 4. Philadelphia, WB Saunders Co, 1972, pp 11-25, 392-408. 25. Morley ME: The Development and Disorders of Speech in Childhood, ed 3. Baltimore, Williams and Wilkins Co, 1972, pp 72-81. 26. Huessy HR: Minimal brain dysfunction in children (hyperkinetic syndrome): Recognition and treatment. Drug Ther 3:52-63, 1973. 27. Bluestone CD, McWilliams BJ, Ross RH: Diagnostic implications of vocal cord nodules in children with cleft palate. Laryngoscope 79:2072\x=req-\ 2080, 1969. 28. Holinger PH, Johnston KC: Benign tumors of the larynx. Ann Oto Rhinol Laryngol 60:496\x=req-\ 509, 1951. 29. Strong MS, Vaughan CW: Vocal cord nodules and polyps: The role of surgical treatment. Laryngoscope 81:911-923, 1971. 30. Ingram TTS: Disorders of speech in childhood. Br J Hosp Med 2:1608-1625, 1969.
Mo
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\s=b\ Psychological and emotional aspects of voice disorders have long received attention from otolaryngologists and speech clinicians. The literature contains frequent reports of such problems, but there are few studies on the full importance of these aspects. The cause of vocal nodules in children has been attributed to vocal abuse, and therapy has consisted of the elimination of this abuse. Reports of long-term followup are few, lending suspicion to both the proposed causes and the therapeutic ap-
proaches.
Seventy-seven prepuberal
children with vocal nodules are studied from the social,
The
child with vocal nodules pre¬
perennial management problem for the otolaryngologist and the speech clinician. It was estimated by the American Speech and Hearing sents
a
Association in 1959 that 5% of all schoolchildren had speech problems of such seriousness that their educa¬ tional, social, and emotional adjust¬ ment was affected.1 Voice deviations found in mass screening programs would indicate that this estimate of incidence is too low.2-4 Senturia and Wilson4 stated that 3% would be a more appropriate estimation for voice disorders that cause a communication for publication May 16, 1975. From the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee. Reprint requests to 5757 W Oklahoma Ave, Milwaukee, WI 53219 (Dr Toohill).
Accepted
medical, and physical aspects. The incidence of vocal nodules approaches 1% of all children. Boys predominate this amount by ratios greater than 3:1, with incidence peaks between ages 5 and 10. Conventional modes of therapy have been unsuccessful because of the lack of recognition of psychosomatic factors. New approaches for therapy are sug-
gested including parental involvement, counseling, group therapy, and drug therapy. Though emotional problems may persist, the somatic aspect of this disease
disappears at puberty. (Arch Otolaryngol 101:591-595, 1975)
handicap. The number of children who actually have vocal nodules is un¬ known, but would appear to approach or
exceed 1% of all children.
REVIEW OF THE LITERATURE
Emotional factors of this disorder in children were suggested by White5 when he stressed that all changes in the voices of children are not to be classified as physiological changes. He thought that the psyche of a child was at stake when voice problems were not thoroughly investigated. Lore," in 1950, noted that one of the confusing aspects surrounding the problem of hoarseness in children was the cause of the condition. He studied 19 pa¬ tients and noted that all either had a history of infection in the respiratory tract or lived in an environment con-
ducive to overuse of the voice. Arnold7 stated that screaming chil¬ dren represented a case of tissue re¬ action to mechanical trauma. This has become known as vocal abuse or mis¬ use, and is widely accepted as the prime cause of vocal nodules in chil¬ dren. Senturia and Wilson4 amplified this concept by stating that vocal abuse was precipitated in children largely as a result of mucopurulent secretions in the nasopharynx due to chronic suppurative or allergic rhinosinusitis. With acceptance of vocal abuse as the cause and the therapeutic ap¬ proach of nonsurgical intervention, the speech clinician inherited a prom¬ inent role in the treatment of chil¬ dren with vocal nodules. Wilson" emphasized an elimination or modi¬ fication of chronic vocal abuse. His techniques, which are a model for all speech clinicians, consist of the imple¬ mentation of a variety of rules that attempt to change the habitual pat¬ tern of laryngeal dysfunction in the child. Many isolated case reports indi¬ cate the success of these methods, but large series are infrequent. Brodnitz and Froeschels" reported successful rehabilitation in two chil¬ dren with habitual dysphonia by use of the chewing method, which is based on the relationship between chewing and vocal functions. Later, in evaluating patients undergoing vo-
Downloaded From: http://archotol.jamanetwork.com/ by a University of California - San Diego User on 06/04/2015
cal that
rehabilitation, Brodnitz noted they invariably were victims of
deep emotional disturbances.10 His 1963 report specifically evaluated 29 children, 20 of whom were treated with speech therapy.11 Nine had good results, seven were somewhat im¬ proved, and four were considered un¬
successful. Four were rehabilitated when recurrence was noted after sur¬ gical removal of the nodules. In 1969, Böhme and Rosse,1- being dissatisfied with only 32 successful rehabilitations in 72 patients with vocal nodules, rec¬ ommended drug therapy that utilized cortisone derivatives and insulin
preparations.
There are several studies of emo¬ tional problems in children with speech and voice deviations. Nemec11 was one of the first to present objec¬ tive evidence when he found that chil¬ dren with hyperkinetic dysphonia were more aggressive. He noted they were more immature and less able to handle stressful situations. Sedlackova,14 in 1960, was the first to state that voice disorders in children were symptoms of anxiety. She believed that this was a reaction to social pres¬ sures and an inherited temperamen¬ tal personality. Mosby,15 in 1967, stud¬ ied 25 children-16 with vocal nodules and nine with hoarse, husky voices. She utilized a battery of psychological tests, and results suggested a neu¬ rotic personality with major conflicts,
over-repressed aggression, inadequa¬ cy feelings, poor relationships with parents, and severe dependency needs. Wilson and Lamb,16 in a study of 12
children with vocal nodules and 12 children who served as controls, con¬ cluded that personality types vary from severely aggressive, out of con¬ trol, to the extremely passive overcontrolled adjustment of aggression. Statistical confirmation of increased anxiety was recorded by Marks et al,17 who utilized the junior form of the Eysenck Personality Inventory (EPI) in a study of 11 children with vocal nodules and 11 control patients. Psychiatric therapy has given lim¬
ited, but, nevertheless, important
re¬
sults. In 1960, Withers and Dawson1"
specifically emphasized therapy that dealt with the psychosomatic aspect. They obtained excellent rehabilita-
tion following psychiatric evaluation and treatment of two children with vocal nodules. Mosby19 treated four boys with voice deviancy by a psycho¬ analytic method of the Rorschach In¬ dex of Repressive Style and obtained excellent clinical results. Connelly et al20 reported an innovative technique that used group therapy for 16 chil¬ dren with vocal nodules. This tech¬ nique appears to have substantial merit, since after only six weeks of therapy, seven children were entirely free of nodules, and the remaining nine showed noticeable voice im¬ provement. The authors specifically emphasized parental participation in all aspects of the program. Greene21 particularly stresses the need for assessment of the home background when therapy is under¬ taken. She further notes that anxiety and stress within the family or at school contribute to the expression of vocal abuse in the child with nodules, and this must be alleviated if therapy is to be successful. Renfrew22 con¬ cludes that increased anxiety is the consistent factor in children with this disorder. I review the social and medical as¬ pects of a group of children with vocal nodules, analyze the various forms of therapy utilized for the group, and describe the results of long-term fol¬
low-up.
METHODS
Seventy-seven
children with vocal nod¬ were included in the study. Children with other laryngeal dis¬ orders were not included. A complete social and medical history was obtained for each
ules, all prepuberal,
patient, including
age, sex,
sibling rank,
and onset of symptoms. Complete otolaryngologic examinations were done on all patients. Mirror laryngoscopy was success¬ ful in 75 of the children. It was not always successful on the first examination, but with patience and proper preparation it could invariably be accomplished on the second or third visit. Direct laryngoscopy was used on two occasions to confirm the impression from an inadequate mirror ex¬ amination. An audiogram was performed on each patient. Therapy was divided into four cate¬ gories: (1) school therapy, in which the pri¬ mary form of therapy given to the child was by the school speech therapist; (2) pro¬ fessional therapy, in which therapy was
given by a professional speech therapist or pathologist in a medical center or hospital; (3) parental involvement and counseling, including psychiatric help; and (4) those who received no specific therapy. A patient was
classified
tion
was
cured if vocal rehabilita¬ This included an ab¬ sence of hoarseness or raspiness, normal pitch, good quality, and a larynx that appeared to be normal. Improvement was recorded if there was a decrease in the de¬ gree of hoarseness or raspiness of voice, a diminution in nodule size, and progress in the elimination of vocal abuse. Patients were considered unimproved if they re¬ mained hoarse or raspy in voice quality, and if there was no improvement in their ability to cope with vocal abuse. as
complete.
SOCIAL AND MEDICAL FINDINGS The Figure illustrates the age of incidence for both boys and girls. Two factors are noteworthy. Boys pre¬ dominate by greater than 3:1, and the peak age of incidence is between the ages of 5 and 10. Girls tend to develop vocal nodules slightly earlier than boys. Of the 77 children, one was an only child. Thirteen were the oldest in the family, and 63 had older brothers or sisters, or both. The sources of referral were as fol¬ lows: pediatricians referred 22 of the children; school speech therapists, 21; parents, 4; other sources (including family physicians, allergists, school physicians, and teachers), 12 children. For six children, the source of referral is unknown. Twelve children were noted to be hoarse and to have vocal nodules when they were being exam¬ ined for other problems. Parents were asked to describe the child's person¬ ality and vocal habits. Sixty-two were described by the parents as scream¬ ers, incessant talkers, or loud talk¬ ers. Sixty-six were said to have one or more of the following personality traits: aggressive, hyperactive, ner¬
tense, frustrated, or emotionally disturbed. Attempts were consist¬
vous,
ently made to seek this informa¬ tion from parents without suggestion from the interviewer. The initial symptom was a raspy or hoarse voice that varied in degree. Many parents described this condition as mild, and described the voice quality as raspy rather than hoarse. Sixty-five pa¬ tients initially had these two com¬ plaints. Of the 12 patients who had
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Table 1.—77 Patients With Vocal Nodules
Type of Disorder* Free of associated disorders
No.
Associated disorders Adenoiditis Chronic otitis media Tonsillitis
31 17 16 14 6 3
Allergy
Adenoid hypertrophy Deviated nasal septum Severe prematurity Speech defects Articulation
Velopharyngeal insufficiency
E
46
1
1 10 6
4
3
6
7
Age at Onset of Disease -· Boys ·
Repaired cleft palate
Submucous cleft Following adeno-
tonsillectomy
Stuttering
5
Girls ·-· 1
* While the number of children with asso¬ ciated disorders was only 31, many children had more than one concomitant disorder.
initially been examined for other problems, ten had symptoms related
or chronic otitis media, adenoiditis, or tonsillitis. The dura¬ tion of symptoms varied, with some having the condition for only one month and others having the condi¬ tion since infancy. Most patients had symptoms for 3 to 12 months. In only three patients could abrupt circum¬
to recurrent
stances be related to the onset of symptoms. These three patients were ages 9,11, and 12, and they were each participating in a group activity. The 9-year-old boy abused his voice while being a quarterback for a football team. The 11-year-old boy noted hoarseness after singing, and the 12year-old girl strained her voice after intense playacting. The onset of symptoms in the re¬
mainder was gradual. Many parents noted more pronounced hoarseness in the spring months of April through June. No parents could recall a defi¬ nite attack of laryngitis as the precip¬ itating factor, and very few could as¬ sociate the hoarseness with upperrespiratory tract infections. Group activity would frequently cause a deterioration of voice. Quality would
Boys represented 71.1 % of affected children. Of total of 60 boys, peak age of incidence was between ages 7 and 10 years (50.9%). Girls represented 28.3% of patients. Peak age of incidence for girls was between 5 and 7 years (70.6%). Peak age of incidence for all children was between 5 and 10 years (84.4%). be
good in the morning, but by evening the child was hoarse, whis¬ pering or had severe "breaking of the voice." Table 1 notes other
previous, con¬ subsequent diseases of the patients. Thirty-one had other
comitant,
or
diseases that were of a chronic nature and that were important during the evaluation and treatment. Many had two or more disorders, but the re¬ maining 46 had no other disorders. Thirteen patients had both chronic otitis media and adenoiditis, and nine patients had a conglomerate of chronic otitis media, adenoiditis, and tonsillitis. These, indeed, were the most frequent concomitant diseases. Six patients were allergic, and six had speech articulation defects. No patient had a severe general physical illness or an endocrine or thyroid disease. Seventy-six of the 77 patients in this series had bilateral vocal nodules. The one exception was the 12-yearold girl who was participating in a play and developed a unilateral vocal nodule. Tension in the sternocleidomastoid and strap muscles, and a pal¬ pable increase in rigidity of the
was frequently noted. Pa¬ tients with otitis media had a mild conductive hearing loss, but no severe sensorineural loss was noted.
tongue
RESULTS OF THERAPY
The primary form of therapy in 33 patients was administered by school speech therapists (Table 2). No treat¬ ment was given to 19 children. Pro¬ fessional speech therapy was em¬ ployed in 13 patients. Twelve were treated only by means of parental in¬ volvement and counseling with psy¬ chological help, particularly from the social worker. Ten of 12 patients in
this group were either cured or im¬ proved and the other two were un¬ available for follow-up. The recovery rate did not vary for the three meth¬ ods of treatment, and it compares fa¬ vorably with those who received no treatment. When all forms of therapy were analyzed, 58.5% of the patients were either cured or improved. One third showed no improvement. Fourteen (28%) of the patients who are still prepuberal have recovered with the prescribed therapy. Fifty pa¬ tients (72%) have persistent nodules. The six patients who are now post-
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puberal have all recovered. Only two of the 77 patients had lar¬
yngoscopy and removal of nodules. One patient had removal after speech therapy, and he had a recurrence of nodules two months postoperatively. The second patient had remarkable improvement due to speech therapy, but hoarseness persisted because the nodule on the right true vocal cord had become slightly larger and poly¬ poid. These nodules were removed by microlaryngoscopy and the patient's rehabilitation was complete. Three other patients who appear to have had good results from therapy are being observed, and may require sur¬ gical removal since puberty is at least four years away. Nine patients are of special inter¬ est, eight of whom have persistent nodules, and one of whom was un¬ available for follow-up. They either had a previous history of, or had psy¬ chological deviations. This figure rep¬ resents 12% of the patients with vocal nodules. The pediatrician, speech pa¬ thologist, social worker, and psycholo¬ gist were helpful in identifying these
patients. Methylphenidate (Ritalin)
hydrochloride was successfully used in two patients. Another patient,
whose father had died,
by
an
understanding
assisted mother who was
used the services of a psychiatric social worker. The fourth patient's psychological problem was of such severity that the parents accepted psychiatric help. There are four other children in this group, and the par¬ ents have been counseled but have not followed through with further psychiatric consultation or therapy. COMMENT In assessing this report and those from the literature, it is interesting to note the sex and age of incidence of children with vocal nodules.4·12·23 The natural phenomenon of aggres¬ siveness becomes prominent in the transition period between the passive dependence of infancy and the inde¬ pendence of childhood. Boys play more aggressive roles in social ex¬ change than girls. Environmental in¬ fluences do not completely account for this sex difference. This common mode of behavior is more readily ap-
Table 2.—Results of Treatment Parental Results of Cured
Therapy
Improved Unimproved Unavailable for follow-up Total
School
No
Counseling Therapy
TO" Tí
Professional 3 4
12
ß"
Ö
4 3 7
0 33
0 13
2 12
5 19
parent in emotionally disturbed chil¬ dren, especially boys, during their preschool and early school years.24
Relating to other speech problems, the predominance of boys in patients with vocal nodules would correspond very favorably with the findings of Morley2·'1 in patients with other speech defects. He noted that males pre¬ dominated at a ratio of 3:1 in defects of articulation, and at a ratio of 2:1 in defects related to stammering. There is also a predominance of boys in chil¬ dren with minimal brain dysfunction who are hyperactive, overactive, or hyperkinetic.26 These terms are often used in describing children with vocal nodules. The development of vocal nodules corresponds to the age at which chil¬ dren enter group activities. The prob¬ lem is frequently not apparent until the child enters school and has to cope with groups on a regular basis. Fam¬ ily position also seems to be of impor¬ tance. Morley2"' has noted that defects of articulation and stammering are substantially higher in children who were not the firstborn. This is also true in children with vocal nodules. When related to the competitive at¬ mosphere sometimes created by older children in the family, this finding should be considered to be important in children with vocal nodules. Other diseases associated with vo¬ cal nodules appear to have aggravat¬ ing influences. The finding of otitis media is considered to be important. Associated conductive hearing loss plays an important role in vocal¬ ization of the patient. In my study, three of the six patients with allergic problems were noted to have aggra¬ vation and increased symptoms of hoarseness during the highly allergic seasons of the year. The anxiety of the patients with an articulation de¬ fect, when exposed to their peer
3 7
Totals, (%) 20 (26.0) 25 (32.5) 25 (32.5) 7(9.0) 77(100)
promotes diminished quality of voice. This was likewise true in the three patients in this series who had velopharyngeal incompetence, emphasizing the high incidence of vocal nodules in children with palatal defects.27 A correlation between the presence of associated diseases and the onset of vocal nodules was not substan¬ tiated in this study. Some children who were seen on repeated visits had findings of mild rhinitis, nasophargroups,
yngitis, or pharyngitis. Suggestions of hypopharyngitis with inflammation of the arytenoids or laryngitis were quite rare.4 The finding of bilateral nodules in 76 patients is high when compared to previous studies,4·28 but it compares favorably with the observations of
Böhme and Rosse.12 One nodule is fre¬ quently larger than the other, and this discrepancy accounts for the fact that only the more prominent nodule is noted. This factor, along with tech¬ nical difficulty in visualizing the child's larynx, could account for the reports of unilateral nodules. Re¬ peated observation and use of microlaryngoscopy reveals that the nodules are invariably bilateral. The most common site of occur¬ rence, as noted by Arnold,7 and pres¬ ent in all cases, was centered at the midpoint of the membranous cord. Of those that have been palpated, all are soft and boggy, and, despite the ap¬ pearance of a more mature nodule, it is rare to find the fibrous, varicose, hyalinized, or polypoid nodules in chil¬ dren. The histologie features have been well described, and indicate an edema of the Rienke layer, with in¬ creased vascularity isolated to the site of occurrence.29 Results of present methods of ther¬ apy cannot be considered successful, especially when compared with the
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progress of children receiving no treatment whatsoever. Proper em¬ phasis should be given to the psycho¬ somatic aspect.1'17 If a mild problem exists, and parents rapidly develop insight into the probable causal as¬ pects, rehabilitation may be well un¬ derway and successful. Parental in¬ volvement, counseling, and group therapy will suffice in the majority of cases.20 The more difficult cases re¬ quire assistance from the speech clini¬
cian, social worker, and possibly the
psychologist or psychiatrist, as em¬ phasized in 12% of the patients in this study. The association of minimal
and other central disorders must be investi¬ gated further. The presence of these associations probably accounts for the efficacy of methylphehidate hydro¬ chloride in selected cases. The otolaryngologist must assume the logical position of control, coordination, and observation of the therapeutic pro¬ brain
dysfunction
nervous
the emotionally over-responsive child, and serve only to add to the anxiety that already exists. Surgical removal is rarely indi¬ cated, and this fact has been well recorded by Arnold7 and Strong and Vaughan.29 The child who has under¬
by
gram.
gone successful vocal and personality rehabilitation may have persistent vocal nodules. The advent of micro¬
Although still advocated, voice rest for extended periods of time is impos¬ sible to achieve in a child.30 Conven¬ tional, rigid-rule enforcement by the speech clinician is fruitless. These two forms of therapy cannot be tolerated
Speech therapy data were acquired with the assistance of Mary J. Marks, MS, and Mary K. Galindo, MS.
scopic techniques has made removal a precise and non-traumatizing event.
References 1. Incidence of serious speech problems in school-age children in the United States. J Am Speech Hear Assoc 1:138, 1959. 2. Baynes RA: Incidence study of chronic hoarseness among children. J Speech Hear Dis-
ord 31:172-175, 1966. 3. Nowak VR, Vollbrecht A: Uber die haufigkeit von stimm-und sprachstorungen bei schulanfangern. Dtsch Gesundheitsw 21:654-658, 1966. 4. Senturia BH, Wilson FB: Otolaryngologic findings in children with voice deviations. Ann Otol Rhinol Laryngol 77:1027-1041, 1968. 5. White FW: Some causes of hoarseness in children. Ann Otol Rhinol Laryngol 55:537-542, 1946. 6. Lor\l=e'\JM Jr: Hoarseness in children. Arch Otolaryngol 51:814-825, 1950. 7. Arnold GE: Vocal nodules and polyps: Laryngeal tissue reaction to habitual hyperkinetic dysphonia. J Speech Hear Disord 27:205-217, 1962. 8. Wilson DK: Voice Problems of Children, Baltimore, Williams & Wilkins Co, 1972, pp 13-52, 119-155. 9. Brodnitz FS, Froeschels E: Treatment of nodules of vocal cords by chewing method. Arch Otolaryngol 59:560-565, 1954. 10. Brodnitz FS: Post-operative vocal rehabilitation in benign lesions of the vocal cords. Folia Phoniatr 7:193-200, 1955. 11. Brodnitz FS: Goals, results and limitations of vocal rehabilitation. Arch Otolaryngol 77:148\x=req-\ 156, 1963.
12. Bohme G, Rosse E: Zur haufigkeit altersverteilung therapie und prognose von stimmlippenknotchen. Folia Phoniatr 21:121-128, 1969. 13. Nemec J: The motivation background of hyperkinetic dysphonia in children: A contribution to psychologic research in phoniatry. Logos
4:28-31, 1961.
14. Sedlackova E: Les dysphonies hypercinetiques des enfants causees par surmenage vocal. Folia Phoniatr 12:48-60, 1960. 15. Mosby D: Predominant personality characteristics of twenty-five children with voice disorders. Read before the American Speech and Hearing Association Convention, Chicago, 1967. 16. Wilson FB, Lamb MM: Comparison of personality characteristics of children with and without vocal nodules on Rorschach protocol interpretation. Read before Regional Conference of American Speech and Hearing Association, Atlanta, 1973. 17. Marks MJ, Galindo MK, Toohill RJ: A psychological survey of children with vocal nodules. J Commun Disord, to be published. 18. Withers BT, Dawson MH: Psychological aspects: Treatment of vocal nodule case. Tex Med
56:43-46, 1960.
19. Mosby DP: Appraising psychotherapeutic change in voice deviant children with the Rorschach Index of Repressive Style. Percept Mot Skills 34:701-702, 1972. 20. Connelly MK, Wilson FB, Leeper HA: A group voice therapy technique for decreasing vocal abuse in children with vocal nodules.
J
Speech
Hear Assoc 3:7-18, 1970. 21. Green MC: The Voice and its
Disorders, ed 3. Philadelphia, JB Lippincott Co, 1972, pp 126\x=req-\ 129. 22. Renfrew CE: Speech Disorders in Children, ed 1. New York, Pergamon Press Inc, 1972, pp 52-54. 23. Heaver L: Psychiatric observations on the personality structure of patients with habitual dysphonia. Logos 1:21-26, 1958. 24. Bakwin H, Bakwin RM: Behavior Disorders in Children, ed 4. Philadelphia, WB Saunders Co, 1972, pp 11-25, 392-408. 25. Morley ME: The Development and Disorders of Speech in Childhood, ed 3. Baltimore, Williams and Wilkins Co, 1972, pp 72-81. 26. Huessy HR: Minimal brain dysfunction in children (hyperkinetic syndrome): Recognition and treatment. Drug Ther 3:52-63, 1973. 27. Bluestone CD, McWilliams BJ, Ross RH: Diagnostic implications of vocal cord nodules in children with cleft palate. Laryngoscope 79:2072\x=req-\ 2080, 1969. 28. Holinger PH, Johnston KC: Benign tumors of the larynx. Ann Oto Rhinol Laryngol 60:496\x=req-\ 509, 1951. 29. Strong MS, Vaughan CW: Vocal cord nodules and polyps: The role of surgical treatment. Laryngoscope 81:911-923, 1971. 30. Ingram TTS: Disorders of speech in childhood. Br J Hosp Med 2:1608-1625, 1969.
Mo
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