http://www.britishvoiceassociation.org.uk/voice-information_children-get-vocal-nodules-too.

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Page updated: 6th May 2011

Children get vocal nodules too!

by Sara Harris, (specialist Speech and Language Therapist and Locum Team
member, Lewisham Voice Clinic); and Lesley Cavalli Cert MRCSLT,
(specialist Speech and Language Therapist, Great Ormond Street Hospital
NHS Trust, London).
What are Vocal Nodules?

Nodules on a child's vocal folds.

Let's just remind ourselves about vocal nodules, what they are and how they
develop. Vocal nodules develop as the result of trauma to the vocal folds.
When the vocal folds collide violently swelling can develop around the site of
the collision. A single episode of trauma, such as shouting, usually recovers
over several days of voice rest, but unfortunately, these episodes are often
repeated so the swelling becomes more persistent and requires treatment.
These swellings are often described as "soft nodules". If soft nodules are
ignored and allowed to progress, the persistent damage may begin to
produce fibrous scar tissue. This makes the affected area stiffer and
therefore less able to vibrate effectively. When this happens we refer to
them as "hard nodules". They are more difficult to treat as they do not
resolve with voice therapy and may require surgery to restore the voice. It
is important to ask your ENT surgeon whether the nodules are soft or hard
as this may make a difference to choosing the most effective treatment.
Can children get vocal nodules?
Children can and do get vocal nodules, although it is important to remember
that not all hoarseness in children is necessarily caused by vocal nodules
any more than it is in adults. When a child develops a hoarse/husky voice it
is usually associated with inflammation of the vocal folds from an infection
(laryngitis) and the voice is back to normal within two weeks. If your child's
voice does not return to normal after two weeks you need to consult your
GP for advice. You can request that your GP refers your child to an ENT

surgeon, or better still, to your nearest Voice Clinic. The ENT surgeon can
examine your child's vocal folds and make a proper diagnosis of the
problem. Once the vocal nodules have been confirmed, the ENT surgeon or
voice clinic team will help you plan the most effective treatment for your
child.
Always investigate!
Hoarseness is simply a sign that your child's vocal folds are not functioning
as well as usual. It is a symptom of a problem and that is why a proper
diagnosis is so important. Children can develop hoarseness for many
reasons just the same as adults can. Sometimes inflammation of the vocal
folds (laryngitis) can develop as a result of allergies or occasionally, from
asthma inhalers, especially when they are not properly administered. Along
with nodules, children can also develop cysts in their vocal folds or a small
scar (known as a sulcus).
Don't Panic!
Occasionally more serious problems can occur. Children can be born with or
develop a paralysed vocal fold for example, and even more rarely the
human papilloma virus can cause warty growths to develop on the vocal
folds. Finally, although it must be stressed that it is extremely rare, vocal
fold cancer in a child has been reported. No need for panic though, these
more serious conditions are very unlikely to happen to your child, they just
need to be excluded for everyone's peace of mind, that is all.
Signs and symptoms
Vocal nodules usually develop slowly over time and tend to come and go to
begin with depending on the circumstances. If your child's voice is usually
clear and sounds normal, the first sign of nodules could be hoarseness
developing after your child has been involved in noisy activities such as
playing sports, going to parties, or quarrelling with brothers or sisters. At
first the hoarse voice usually recovers after a few days, but if these
situations occur often you may notice that the hoarseness becomes more
persistent. Some children are hoarse during term time but improve with
vocal rest over the holidays. Their voices may sound rough and breathy and
cut out often, especially at certain pitches. Your child may seem to have to
shout all the time. If they try to be quiet the voice may disappear to a
whisper. They often sound worse in the morning and take some time to get
their voices going. They will also usually sound deeper in pitch than other
children.
Clues from the history
Some children are born with obvious voice problems. Their cries at birth and
during babyhood are not normal and they are therefore usually diagnosed
early as the problem is easy to spot. Perhaps the most common problem
with this sort of history would be paralysed vocal fold or some other
developmental vocal fold abnormality. Other early voice problems are less
easy to spot but with hindsight share a clear history. Mothers typically report
these children as being louder and deeper in pitch than other children their

age. As their voice use increases with social development, especially when
shouting, singing or acting are involved, the voice deteriorates and becomes
more persistently hoarse. However, the severity of the hoarseness is
variable and often improves with rest. This sort of history would tend to
suggest that the child has a cyst rather than vocal nodules.
The more serious problems, such as papilloma, start with a mild but
unvarying hoarseness which becomes steadily worse with time. The child is
likely to develop difficulties breathing, becoming short of breath or breathing
noisily as the papilloma begins to reduce the available space in the airway.
These symptoms should be reported to your doctor and investigated
immediately
Treatment Today
In most cases vocal nodules in children can be treated successfully with
conservative measures. They may resolve with rest alone in their acute
stage if the child rests his/her voice, but if the trauma occurs repeatedly,
then treatment will be required. Voice therapy is usually the treatment of
first choice. Voice therapy exercises are designed to restore efficient vocal
function so that the nodules resolve. The therapy approach is also likely to
involve some behaviour modification around the child's/family's lifestyle,
making them aware of situations which are damaging to voices and trying to
minimize or avoid them. It is best if the parents are closely involved in the
treatment programme. They will need to help determine activities and
behaviours that are associated with the voice problem, and to supervise
vocal exercises and a reward scheme to reduce episodes of shouting or
vocal abuse. Similarly the help of the teacher and school will be needed to
ensure that the voice problem is properly understood and that the treatment
programme is continued in school time.
My child won't do the exercises!
Some children are notoriously unconcerned about whether their voices are
hoarse or may just be too young to take things on board. In fact it is often
the teacher or parent who notices the problem initially and is concerned to
get it diagnosed and treated. Fortunately, once a diagnosis of vocal nodules
is confirmed, it is not life threatening and if your child will not co-operate
with the voice therapy and lifestyle changes suggested nothing dire will
happen. As your child grows and changes, the nodules and voice problem
may resolve on their own. If not treatment can always be carried out later
when your child can accept it or is old enough to understand its importance.
Keeping things "cool"
Emotion is a major factor in the development of voice problems in both
children and adults. Often it is not the shouting as such that does the
damage, but the emotion behind the shouting. Children and parents
frequently report that the hoarseness is worse during quarrels and
disagreements. Children frequently wind each other up with the things they
do and also the things they say. Some children seem particularly susceptible
to expressing their rage and frustration through tight and constricted voice

use, especially if they are less verbally adept than their siblings. Children
also pick up on anxieties and friction between their parents or generally in
the family. These situations affect us all at times and it is important to keep
alert to our children and pick up when they need reassurance and a chance
to talk about real things in a simple way. Try to give them plenty of time to
know about and prepare for big changes, such as moves of house or school,
deaths in the family or divorce. If you are concerned about your child's
emotional state help is available through your GP or local family therapy
service.
What happens if the vocal nodules are hard?
Sometimes vocal nodules in children do become hard and fibrous and voice
therapy is unable to resolve the voice problem fully. Adults with hard
nodules may be offered surgery; however, many surgeons prefer not to offer
surgery to children until they have reached adolescence. The reason for this
is partly to do with the layered structure of the vocal fold, which develops
during childhood but is not fully mature until approx 10 years old. (see "the
secret is in the structure" section on vocal nodules in adults). It is also
because vocal nodules are not a danger to the child's health and it is safe
simply to monitor them until they either resolve or the child is mature
enough to benefit from therapy or surgery. Nodules may recur after surgery
if the child/young person is unable to improve their vocal habits sufficiently.
Help is at Hand
If your child has symptoms that suggest he/she might have vocal nodules:

Seek a medical opinion from a Laryngologist experienced with voice

problems. The best solution is to ask your GP for a referral to a
multidisciplinary voice clinic. A list of UK voice clinics is available to
download here

Whenever possible insist on some quiet time/activities so your child

can rest his/her voice and try to keep them away from having to speaking
against noise or shout

Coughing is often reduced by steam inhalations. They also soothe

irritated and swollen vocal folds

Keep your child well hydrated and away from inhaled irritants, such as
smoke.

If your child is a singer discuss suitable warm up exercises with his/her

singing teacher

If your Laryngologist refers your child to a Speech and Language

Therapist take up the option and work hard on the exercises you are given.
Voice therapy is like physiotherapy or Pilates for the voice and may well be
all your child needs to resolve the nodules.

If your Laryngologist suggests surgery, then ask them to explain

exactly what they will do at surgery and why they feel it is the best
treatment option. Discuss any worries you have openly. It may be the right
way to deal with the problem if your child is older, has already worked hard

to successfully change their vocal behaviours but the voice problem has
not resolved sufficiently. Discuss this with your child's ENT Surgeon and
Speech and language Therapist so that you can make a decision you feel is
right for your child and then plan voice care after surgery carefully.
Don't blame yourself or your child for it! Vocal nodules are not a crime. They
are just an injury that can happen, much as a child can get from playing
sports or even in the playground.