Dr. Sneha Chandrasekhar

1. PAEDIATRIC VOICE
DISORDERS
Dr. Sneha Chandrasekhar

2. VOICE
• Voice: referred to as ‘speech’ as a whole.
• Acoustic outputs resulting from interaction of vocal fold
vibrations with the vocal tract
• Phonation - Physical & Physiological process of vocal
fold vibration in production of speech sounds
• Plays vital role in the expression of emotional and
linguistic communication.

3.  Air & Pressure system :
Lungs and muscles of chest
wall
Vibratory system: sound
produced by vocal fold
vibration
Vocal Tract:
Resonators: Throat, oral cavity,
and nasal passages
Articulators: Tongue, soft
palate, and lips
Modify sound and produce
words

4. SRUCTURE OFVOCAL FOLD
Outer Cover
Epithelium and Superficial
layer of lamina propria
Least stiffness, most
movement
Transition layer
Intermediate and deep layer
Lamina propria
Longitudinal stability

5. • Body
Thyroarytenoid muscle/Vocalis
– Most stiffness
– Least movement
• Disruption-Voice disorders

6. Vocal fold development
AT BIRTH
 Layer structure is absent
 Starts to differentiate over the first few months
YOUNG CHILD
 1-5 years : bilaminar structure
 Absent collagen and elastin
 Severe mechanical stress with increased voice use.

7. TEENAGE
 Differentiation of superficial and deep layers of lamina
propria (vocal ligament)
 Increased % of collagen
 Increased ability to tolerate impact stress
 Up to 10 years Vocal cord length : 6-8 mm
 Membranous vocal cord growth greater in males (14-
18mm) than females (8.5-12mm)

8. PHYSIOLOGY OF PHONATION
INITIATION: Prephonation
inspiratory phase
Each vibratory cycle has 3
phases :
Adduction
Aerodynamic separation
Elastic recoil

9. THEVIBRATORY CYCLE
• Myoelastic aerodynamic theory of phonation by
Van Den Berg (1958)

10. • Body-cover theory of vocal fold vibration by
Hirano(1974)

11. Characteristics of voice
• FREQUENCY
• AMPLITUDE
• QUALITY

12. FREQUENCY
 Rate of vocal fold vibration (Hertz)
 Fundamental frequency : F0
 Children 270-300 Hz
 Pubescence 85-180 Hz – males 155-300 Hz – females
 Depends on
– Vocal fold length, mass, and tension
 Jitter

13. Amplitude
Size of oscillation of vocal fold (loudness)
Relates to two features of voice
 Amount of airflow from the lungs
 Amount of resistance to the airflow by the vocal fold
Shimmer

14. QUALITY
Nature of adduction and vibratory
characteristics of vocal fold
Incomplete adduction : Breathy voice
Irregular mucosal wave form : Hoarse voice
Resonance : eg. Hyponasal / Hypernasal

15. WHAT IS A DISORDEREDVOICE?
• not audible, clear or stable in a wide range of acoustic
settings
• not appropriate for gender and age of speaker
• not capable of fulfilling linguistic and paralinguistic
functions
• fatigues easily
• associated with discomfort & pain on phonation

16. Hoarseness / Dysphonia
Stridor
Dyspnea
Aphonia
Voice breaks
Excessively loud voice
Inability to sustain a note when singing
Effortful or strained voice

17. Onset of dysphonia
After Birth
 Anatomic
 Neurologic
 Inflammatory
 Infectious
 Iatrogenic
 Neoplastic
Since Birth
 Congenital
 Neurologic

18. Paediatric voice disorders
Congenital
 VF Paralysis
 Laryngeal stenosis
 Webbing
 Cleft lip
 Cleft Palate
 Acquired
 Laryngeal trauma
 Hyperfunction w/o lesion
 Vocal nodules
 Vocal polyps
 Vocal fold cysts/Sulcus
 Contact ulcers
 VF paralysis
Organic Functional
 Muscle tension
Dysphonia
 Puberophonia
 Dysphonia Plica
Ventricularis

19. Vocal nodules
 Commonest cause of dysphonia in children
 callous-like lesions
 junction of the ant and middle third of true
cords
 usually bilateral
 Result from vocal abuse and overuse
 reversible with voice therapy
 Spontaneous resolution more common in
Boys

20. Causes ofVocal strain
• Shouting, cheering, and screaming
• Grunting
• Throat clearing
• Coughing, loud forceful sneezing,
• Crying, laughing, loud and long
outbursts of emotions
• Restricted fluid intake

21. Laryngeal web
web of tissue is left across the laryngeal inlet
3 types : <35% 50% 75%
Weak cry occasionally stridor
Arrest of vocal fold separation
Can be surgical divided

22. Vocal polyps
Benign swelling
Generally unilateral
Single traumatic
episode/chronic
Sessile/ Pedunculated
surgical excision

23. Vocal fold cysts
Congenital or acquired
fluid filled epithelial sac in membranous fold
Usually unilateral
Encapsulated growth.
Well circumscribed
Contralateral tissue thickening

24. Papillomas
Wart-like growths of the larynx
and tracheobronchial tree
Lesions may resemble a
raspberry or small
grape-like cluster
Recurrent
Viral etiology HPV 6, 11
hoarseness, aphonia, stridor

25. • Localised invagination of mucosa
• “Open cyst”
• Physiological sulcus: Upto
superficial Lamina Propria
• Sulcus vergeture : UptoVocal
ligament
• Sulcus vocalis: upto thyroarytenoid
Sulcus

26. Granuloma
Benign lesions on the vocal processes.
Endotrachial intubation
Gastroesophageal reflux
Vocal abuse

27. Vocal cord paralysis
• > 50% Bilateral paralysis
• more breathing problems than voice problems
• UnilateralVF paralysis : Hoarse, weak and breathy cry
• Spontaneous improvement 6-12 months by
contralateral cord compensation

28. FUNCTIONALVOICE DISORDERS
• Alteration in voice quality without structural / neurological
pathology : Hyperfunction of laryngeal muscles, (MTD)
Puberphonia (mutational falsetto)
• High pitched voice produced primarily by adolescent or adult
male.
• Voice is deeper on non- phonatory tasks such as coughing-
key
• Treatment : train to attain appropriate low voice pitch,
manipulation of position of larynx, use of coughing/clearing
of throat/grunting to achieve lower pitched voice

29. Laryngopharyngeal reflux in
children
 Chronic cough
 Hoarseness
 Noisy breathing (stridor)
 Reactive airway disease (asthma)
– 50-60% incidence of GERD in
children with asthma
 Spit up
 Feeding difficulty
 Turning blue (cyanosis)
 Aspiration
 Pauses in breathing
(apnea)
 Apparent life threatening
event (ALTE)
 Failure to thrive (< 5th
Percentile)

30. Multidisciplinary approach
 ENT
PCP/Pediatrician
Speech Language Pathologist
Pediatric Pulmonary Specialist
Pediatric Gastroenterologist
Pediatric Neurologist

31. Evaluation
History
General Examination & Visualization
Diagnosis

32. History
 Complete case history
– Pregnancy and birth
– Developmental
– Other medical issues
 Date of onset
– Since birth
– New onset
 Associated difficulty
– Swallowing
– Breathing
 Patterns of hoarseness
 Intermittent
 Recurrent
 Persistent
 Progressive

33. Vocal hygiene questions
Evidence of
– Yelling
– Screaming
– Making odd noises
with voice
– Extreme emotions
Behavior patterns
Activity level
Eating

34. EXAMINATION
• oral cavity
• oropharynx
• nasal cavity
• external laryngeal skeleton and position
• Posture
• breathing pattern and general affect

35. Voice assessment
Quality of life measures
◦ Pediatric Voice Handicap Index
◦ Pediatric Voice Outcomes Surveys
◦ Pediatric Voice Related Quality of Life
Important to monitor progress before and after
intervention

37. Perceptual evaluation
• GRBAS
• CAPE-V Consensus Auditory-Perceptual
Evaluation of Voice (CAPE-V)

38. GRBAS SCALE
 Grade
 Roughness
 Breathiness
 Asthenia
 Strain
 Scale of 0–3
 Example: G3R2B3A3S2
 The rating is made by assessing current conversational speech or
when reading a passage.

39. OBJECTIVEVOICE
MEASUREMENTS
• Objective, quantitative
noninvasive
• Voice signal recorded
• Converted to electrical signal
• Waveform and spectrum
• Map out phonatory characteristics, demonstrate
phonatory deficits, and correlate findings
ACOUSTIC ANALYSIS

40. PARAMETERS OF ASSESSMENT
1. Pitch assessment
2. Sound pressure level
3. Jitter and Shimmer
ELECTROLARYNGOGRAPHY
Uses principle of electrical impedance across tissue
and open space
Signal is unaffected by resonances of vocal tract
More accurate fundamental frequency

41. Contact Quotient
• When a voice is hoarse,
the percentage of
phonatory contact goes
down
• Increased - e.g- Reinke’s edema
• Decreased- vocal fold palsy/
paresis MTD

42. AERODYNAMIC MEASUREMENT
AirVolume
Air flow
Air Pressure

43. MAXIMUM PHONATIONTIME
 time a person can sustain the vowel
/ah/ at a
comfortable pitch and loudness
 Best of three attempts
 measure of respiratory and sound
control.

44. S/Z Ratio
Ratio of length of time a person can sustain the
/s/ sound to length of time they can sustain the
/z/sound.
Normal 1:1
higher the number, the greater the dysphonia

45. Visualisation
• Indirect Laryngoscopic
• Halogen light Endoscopy
◦ Gross assessment of laryngeal structure
◦ Glottic margins
◦ Color of laryngeal tissue
◦ Symmetry of arytenoid complex
◦ Signs of LPR
Erythemic (red) laryngeal tissue, particularly in posterior larynx
Edema – particularly of the infra-glottic edge
“pseudosulcus”

46. Flexible fibreoptic endoscopy
infant and pediatric larynx
entire larynx and
nasopharynx
Can view larynx
dynamically
40% laryngeal pathologies
missed without
stroboscopic light

47. Rigid endoscopy
 70/90 Degree
 Increased magnification
 Better Optics
 More laryngeal details and
function
 Can only assess phonation
on sustained /i/

48. Video stroboscope
Apparent slow motion for laryngeal and voice evaluation
 Glottal closure
 Pliability/ amplitude
 Mucosal wave
 Symmetry
 Regularity
 Fundamental frequency

49. • Diagnostic micro-laryngoscopy

50. THERAPY
• VOCAL HYGIENE DIETARY & LIFESTYLE
• VOICETHERAPY
• MEDICALTREATMENT
• PHONOSURGERY

51. Approaches
Indirect Intervention
 Educate parents and patients
regarding the problem
 Reassurance
 Counselling
 Vocal hygiene : eliminating
habitual cough, throat clearing
 General relaxation
Direct
Intervention
 Facilitative
techniques
Eg.Yawn-sigh/
specific laryngeal
relaxation
 Voice therapy
programmes

52. Behavioural voice therapy :
Objectives
Hygiene Awareness
General Awareness of Voice
Reduce Laryngeal Tension
Improve
– Respiratory effort
– Vocalization

53. Behavioural voice therapy
Ages 1-4
 By parents, caregivers
 Education of parents regarding voice use and vocal
hygiene.
 Encouraging quiet time
 Education of siblings for support
 Importance of communication

54. Age 4 and older
 2 Stages :
 1st stage: 10 exploratory session to determine goals and
specific procedures, 35-40 minutes
 Second stage: Voice therapy sessions
 Weekly at first
 Home practice to hasten resolution
 4-5 months

55. • MUSCULOSKELETALTENSION REDUCTION

56. Surgery
Phonosurgery: Refers to any surgery designed primarily for the
maintenance, restoration or enhancement of the voice.
 Vocal Nodules
 Vocal Polyps
 Vocal Cysts
 Vocal Fold Paralysis
 Granuloma/Contact ulcer

57. Laryngeal injection
techniques-
materials are usually injected
laterally to augment the vocal fold
• Materials used- teflon, fat,
glycerine, collagen, silicone, Ca
hydroxyapatite
• UnilateralVF palsy, vocal fold
atropy/scar/sulcus vocalis

58. Reinnervation technique
• Used for restoring tone to the vocal fold.
• Non Selective- Unilateral RLN Palsy, with ansa cervicalis
• Selective : Bilateral RLN palsy-C3 root of phrenic nerve with
cable graft harvested from Greater auricular nerve inY
shape and inserted in Post. Cricoarytenoid
Descending branch of ansa - Hypoglossi and RLN
Neuromuscular pedicle : Block of Omohyoid with ansa
cervicalis placed into posterior cricoarytenoid

59. THANKYOU