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Vocal fold nodules in children: preferable therapy
International Journal of Pediatric Otorhinolaryngology 49 Suppl. 1 (1999) S303 – S306 www.elsevier.com/locate/ijporl
Vocal fold nodules in children: preferable therapy Kazunori Mori * Department of Otolaryngology, Head and Neck Surgery, Kurume Uni6ersity School of Medicine, 67 Asahi-machi, Kurume 830 0011, Japan
Abstract Background: The purpose of this paper is to know the preferable treatment for vocal fold nodules in children. Methods: Two hundred and fifty nine patients with vocal fold nodules (176 males and 83 females) were retrospectively reviewed. Age ranged from 2 to 18 years with a mean age of 9 years. In addition, questionnaire survey was carried out, asking about their present voice. Results: Sixteen percent of the patients showed improvement by vocal hygiene advice. Fifty two percent of patients receiving voice therapy showed some improvement. Eighty nine percent of patients showed some improvement by endolaryngeal microsurgery. With respect to the influence of puberty upon the voice, there was no significant difference among vocal hygiene, voice therapy, and no-treatment for pre-puberty cases. Surgical treatment was the only reliable method to acquire voice improvement for pre-puberty cases. In contrast, following puberty there was no significant difference in voice improvement among treatment modalities. Conclusion: If the patient needs immediate improvement of voice, surgery is preferable. If they need the improvement of voice but do not hurry up, voice therapy should be carried out. If patients have no motivation, vocal hygiene is recommended. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Children; Vocal fold nodule; Vocal hygiene; Voice therapy
1. Introduction Treatment for vocal fold nodules in children is still under controversy and is not an easy task [1]. One of the reasons for this is that in many cases children with nodules do not think their hoarse voice as abnormal one. Another reason is that in many cases their voice is thought to improve * Corresponding author. Tel.: +81-942-317575; fax: + 81942-371200. E-mail address: [email protected] (K. Mori)
spontaneously after puberty. The purpose of this paper is to know the preferable treatment for these lesions, by comparing the results of various treatment modalities of juvenile nodules and by investigating the influence of puberty upon voice in those children.
2. Patients and methods During the period of 25 years, 259 patients with vocal fold nodules (176 males and 83 females)
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 1 8 1 - 0
S304
K. Mori / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S303 – S306
were seen in the Kurume University Hospital. Their age ranged from 2 to 18 years with a mean age of 9 years. Treatment methods were classified into four categories: (1) vocal hygiene; (2) voice therapy; (3) surgery; and (4) reassurance and follow up, i.e. no treatment. The following is the intervention strategy adopted in the Kurume University Hospital. Forty seven patients were given simple counseling regarding reduction of vocal abuse and misuse, that is, vocal hygiene advice. Voice therapy was performed to 122 patients, with the use of accent method which included an elementary vocal hygiene advice as well. Fourty three patients underwent endolaryngeal microsurgery. Laser surgery was not employed. Fourty seven patients were reassured and followed up without any further treatment and they were classified into notreatment cases in this study. To investigate the influence of puberty upon the voice, questionnaire survey was carried out. Two questions were asked: (1) ‘‘Have you already reached puberty?’’; and (2) ‘‘How is your present voice?’’. Data from cases who have not yet reached puberty were obtained from 59 cases. With respect to cases who are now after puberty, data were obtained from 120 cases.
3. Results and discussion Table 1 shows the results of the counseling and vocal hygiene advice. Voice of the patients was evaluated perceptually by laryngologists and speech pathologists about 10 months after the initial counseling session. Only four patients’ voices became normal and 1 patient showed a Table 1 Results of vocal hygiene program (n= 47) Voice
Number of subjects
Normal Improved No change Deteriorated Not available
4 0 20 1 22
(16%) (0%) (80%) (4%)
Table 2 Results of voice therapy (n =122) Voice
Number of subjects
Normal Improved No change Not available
20 (22%) 27 (30%) 43 (48%) 32
deterioration. In 22 patients evaluation was not available. Thus, only 16% of the patients showed improvement by this line of treatment. It is thought that most children did not or could not follow the vocal hygiene program. It should be stressed that the patients had no subjective complaint and hence were not motivated to follow that advice. The results of voice therapy are shown in Table 2. This was evaluated perceptually by speech pathologists after treatment had been carried out. In 32 patients evaluation was not available. Fifty two percent of patients receiving voice therapy showed some improvement by this treatment. The relationship between the number of sessions of voice therapy and the results are shown in Table 3. In voice therapy cases, 54 patients underwent voice therapy only once or twice. In this group only nine patients (17%) showed voice improvement. On the contrary, in 26 patients who underwent voice therapy more than seven times, 18 patients (69%) showed improvement. Most patients did not attend voice therapy as seriously as had been expected. However, the more times patients received voice therapy, the more improvement they could obtain. Again, it is motivation of the patient which decides the outcome of the voice therapy. Therefore, when the patient Table 3 Relationship between the number of sessions of voice therapy and the results (n =122) Number of sessions
Number of subjects
Voice improved
1–2 3–6 75
54 42 26
9(17%) 20 (48%) 18 (69%)
K. Mori / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S303 – S306 Table 4 Results of surgery (n = 43)
S305
Table 6 Present voices of voice therapy cases
Voice
Number of subjects
Number of subjects
Pre-puberty
Post-puberty
Normal Improved No change
20 (47%) 18 (42%) 5 (12%)
Normal Improved No change Deteriorated Total
4 8 9 0 21
20 27 7 0 54
(19%) (38%) (43%) (0%)
(37%) (50%) (13%) (0%)
would like to have voice improvement, having strong motivation, voice therapy should be recommended. Table 4 shows the results of endolaryngeal microsurgery. This was evaluated perceptually by laryngologists about 1 month after operation, on average. In total 89% of patients showed some improvement by phonosurgery. Therefore, when the patient wants immediate improvement of voice, endolaryngeal microsurgery should be carried out. However, the recurrence rate after surgery could not be assessed. With respect to the no-treatment cases, no results could be obtained, because almost all patients did not come back to our clinic again. Present voices of vocal hygiene cases are shown in Table 5. In the pre-puberty group of cases, in total eight patients (73%) showed some improvement. In the post-puberty group of cases, 12 patients (67%) showed some improvement. With respect to present voices of voice therapy cases, in total 57% of pre-puberty cases showed some improvement while 87% of post-puberty cases showed some improvement (Table 6). Present voices of surgery cases are shown in Table 7. In all pre-puberty cases their voice showed improvement. Also, 93% of post-puberty cases showed some improvement.
With respect to present voices of no-treatment cases, only 56% of pre-puberty cases showed some improvement (Table 8). In contrast, all post-puberty cases showed some improvement. Therefore, for pre-puberty cases there was no significant difference among vocal hygiene, voice therapy, and no treatment. Surgical treatment was the only reliable method to acquire voice improvement. An outcome of these conservative treatment should not be expected too much. In contrast, following puberty there was no significant difference in voice improvement among treatment modalities. No matter what treatment patients had received, most patients had voice improvement after puberty. With respect to the preferable treatment of vocal fold nodules, it can be concluded as follows, based upon the results of this study: 1. If the patient is in trouble as a result of hoarseness, and immediate improvement of their voice is necessary, surgery is preferable. 2. If they need the improvement of voice but they do not hurry up, voice therapy should be carried out. In this case, strong and repeated encouragement and motivation is necessary to continue undergoing voice therapy. Instead, when no improvement is observed despite
Table 5 Present voices of vocal hygiene cases
Table 7 Present voices of surgery cases
Number of subjects
Pre-puberty
Post-puberty
Number of subjects
Pre-puberty
Post-puberty
Normal Improved No change Deteriorated Total
1 7 3 0 11
5 7 6 0 18
Normal Improved No change Deteriorated Total
0 4 0 0 4
15 11 2 0 28
(9%) (64%) (27%) (0%)
(28%) (39%) (33%) (0%)
(0%) (100%) (0%) (0%)
(54%) (39%) (7%) (0%)
K. Mori / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S303 – S306
S306
Table 8 Present voices of no-treatment cases Number of subjects
Pre-puberty
Post-puberty
Normal Improved No change Deteriorated Total
4 9 9 1 23
7 13 0 0 20
(17%) (39%) (39%) (4%)
(35%) (65%) (0%) (0%)
voice therapy and their dysphonia is severe, surgical treatment should be carried out. 3. If patients have no motivation, vocal hygiene is recommended. However, much and lasting improvement cannot be expected from this line of treatment, because patients without motivation often do not follow the instructions. After puberty, no matter what treatment patients receive, their voice will improve in the ma-
.
jority of the patients. Instead no patient showed a deterioration of voice after puberty. One important point is the fact that about 12% of patients with vocal fold nodules do not show any improvement of their voice even after puberty. These patients may have another minor organic lesions such as shallow sulcus vocalis or may have some psychological problems. However, if the patient has no motivation, it is very difficult even to observe his/her glottis during phonation with the use of laryngostroboscope. Further investigation is necessary on this point.
References [1] J. Hirschberg, P.H. Dejonckere, M. Hirano, K. Mori, H.J. Schultz-Coulon, K Vrticka, Voice disorders in children, Ped. Otorhinolaryngol. (suppl) 32 (1995) 109 – 125.
Vocal fold nodules in children: preferable therapy Kazunori Mori * Department of Otolaryngology, Head and Neck Surgery, Kurume Uni6ersity School of Medicine, 67 Asahi-machi, Kurume 830 0011, Japan
Abstract Background: The purpose of this paper is to know the preferable treatment for vocal fold nodules in children. Methods: Two hundred and fifty nine patients with vocal fold nodules (176 males and 83 females) were retrospectively reviewed. Age ranged from 2 to 18 years with a mean age of 9 years. In addition, questionnaire survey was carried out, asking about their present voice. Results: Sixteen percent of the patients showed improvement by vocal hygiene advice. Fifty two percent of patients receiving voice therapy showed some improvement. Eighty nine percent of patients showed some improvement by endolaryngeal microsurgery. With respect to the influence of puberty upon the voice, there was no significant difference among vocal hygiene, voice therapy, and no-treatment for pre-puberty cases. Surgical treatment was the only reliable method to acquire voice improvement for pre-puberty cases. In contrast, following puberty there was no significant difference in voice improvement among treatment modalities. Conclusion: If the patient needs immediate improvement of voice, surgery is preferable. If they need the improvement of voice but do not hurry up, voice therapy should be carried out. If patients have no motivation, vocal hygiene is recommended. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Children; Vocal fold nodule; Vocal hygiene; Voice therapy
1. Introduction Treatment for vocal fold nodules in children is still under controversy and is not an easy task [1]. One of the reasons for this is that in many cases children with nodules do not think their hoarse voice as abnormal one. Another reason is that in many cases their voice is thought to improve * Corresponding author. Tel.: +81-942-317575; fax: + 81942-371200. E-mail address: [email protected] (K. Mori)
spontaneously after puberty. The purpose of this paper is to know the preferable treatment for these lesions, by comparing the results of various treatment modalities of juvenile nodules and by investigating the influence of puberty upon voice in those children.
2. Patients and methods During the period of 25 years, 259 patients with vocal fold nodules (176 males and 83 females)
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 1 8 1 - 0
S304
K. Mori / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S303 – S306
were seen in the Kurume University Hospital. Their age ranged from 2 to 18 years with a mean age of 9 years. Treatment methods were classified into four categories: (1) vocal hygiene; (2) voice therapy; (3) surgery; and (4) reassurance and follow up, i.e. no treatment. The following is the intervention strategy adopted in the Kurume University Hospital. Forty seven patients were given simple counseling regarding reduction of vocal abuse and misuse, that is, vocal hygiene advice. Voice therapy was performed to 122 patients, with the use of accent method which included an elementary vocal hygiene advice as well. Fourty three patients underwent endolaryngeal microsurgery. Laser surgery was not employed. Fourty seven patients were reassured and followed up without any further treatment and they were classified into notreatment cases in this study. To investigate the influence of puberty upon the voice, questionnaire survey was carried out. Two questions were asked: (1) ‘‘Have you already reached puberty?’’; and (2) ‘‘How is your present voice?’’. Data from cases who have not yet reached puberty were obtained from 59 cases. With respect to cases who are now after puberty, data were obtained from 120 cases.
3. Results and discussion Table 1 shows the results of the counseling and vocal hygiene advice. Voice of the patients was evaluated perceptually by laryngologists and speech pathologists about 10 months after the initial counseling session. Only four patients’ voices became normal and 1 patient showed a Table 1 Results of vocal hygiene program (n= 47) Voice
Number of subjects
Normal Improved No change Deteriorated Not available
4 0 20 1 22
(16%) (0%) (80%) (4%)
Table 2 Results of voice therapy (n =122) Voice
Number of subjects
Normal Improved No change Not available
20 (22%) 27 (30%) 43 (48%) 32
deterioration. In 22 patients evaluation was not available. Thus, only 16% of the patients showed improvement by this line of treatment. It is thought that most children did not or could not follow the vocal hygiene program. It should be stressed that the patients had no subjective complaint and hence were not motivated to follow that advice. The results of voice therapy are shown in Table 2. This was evaluated perceptually by speech pathologists after treatment had been carried out. In 32 patients evaluation was not available. Fifty two percent of patients receiving voice therapy showed some improvement by this treatment. The relationship between the number of sessions of voice therapy and the results are shown in Table 3. In voice therapy cases, 54 patients underwent voice therapy only once or twice. In this group only nine patients (17%) showed voice improvement. On the contrary, in 26 patients who underwent voice therapy more than seven times, 18 patients (69%) showed improvement. Most patients did not attend voice therapy as seriously as had been expected. However, the more times patients received voice therapy, the more improvement they could obtain. Again, it is motivation of the patient which decides the outcome of the voice therapy. Therefore, when the patient Table 3 Relationship between the number of sessions of voice therapy and the results (n =122) Number of sessions
Number of subjects
Voice improved
1–2 3–6 75
54 42 26
9(17%) 20 (48%) 18 (69%)
K. Mori / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S303 – S306 Table 4 Results of surgery (n = 43)
S305
Table 6 Present voices of voice therapy cases
Voice
Number of subjects
Number of subjects
Pre-puberty
Post-puberty
Normal Improved No change
20 (47%) 18 (42%) 5 (12%)
Normal Improved No change Deteriorated Total
4 8 9 0 21
20 27 7 0 54
(19%) (38%) (43%) (0%)
(37%) (50%) (13%) (0%)
would like to have voice improvement, having strong motivation, voice therapy should be recommended. Table 4 shows the results of endolaryngeal microsurgery. This was evaluated perceptually by laryngologists about 1 month after operation, on average. In total 89% of patients showed some improvement by phonosurgery. Therefore, when the patient wants immediate improvement of voice, endolaryngeal microsurgery should be carried out. However, the recurrence rate after surgery could not be assessed. With respect to the no-treatment cases, no results could be obtained, because almost all patients did not come back to our clinic again. Present voices of vocal hygiene cases are shown in Table 5. In the pre-puberty group of cases, in total eight patients (73%) showed some improvement. In the post-puberty group of cases, 12 patients (67%) showed some improvement. With respect to present voices of voice therapy cases, in total 57% of pre-puberty cases showed some improvement while 87% of post-puberty cases showed some improvement (Table 6). Present voices of surgery cases are shown in Table 7. In all pre-puberty cases their voice showed improvement. Also, 93% of post-puberty cases showed some improvement.
With respect to present voices of no-treatment cases, only 56% of pre-puberty cases showed some improvement (Table 8). In contrast, all post-puberty cases showed some improvement. Therefore, for pre-puberty cases there was no significant difference among vocal hygiene, voice therapy, and no treatment. Surgical treatment was the only reliable method to acquire voice improvement. An outcome of these conservative treatment should not be expected too much. In contrast, following puberty there was no significant difference in voice improvement among treatment modalities. No matter what treatment patients had received, most patients had voice improvement after puberty. With respect to the preferable treatment of vocal fold nodules, it can be concluded as follows, based upon the results of this study: 1. If the patient is in trouble as a result of hoarseness, and immediate improvement of their voice is necessary, surgery is preferable. 2. If they need the improvement of voice but they do not hurry up, voice therapy should be carried out. In this case, strong and repeated encouragement and motivation is necessary to continue undergoing voice therapy. Instead, when no improvement is observed despite
Table 5 Present voices of vocal hygiene cases
Table 7 Present voices of surgery cases
Number of subjects
Pre-puberty
Post-puberty
Number of subjects
Pre-puberty
Post-puberty
Normal Improved No change Deteriorated Total
1 7 3 0 11
5 7 6 0 18
Normal Improved No change Deteriorated Total
0 4 0 0 4
15 11 2 0 28
(9%) (64%) (27%) (0%)
(28%) (39%) (33%) (0%)
(0%) (100%) (0%) (0%)
(54%) (39%) (7%) (0%)
K. Mori / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S303 – S306
S306
Table 8 Present voices of no-treatment cases Number of subjects
Pre-puberty
Post-puberty
Normal Improved No change Deteriorated Total
4 9 9 1 23
7 13 0 0 20
(17%) (39%) (39%) (4%)
(35%) (65%) (0%) (0%)
voice therapy and their dysphonia is severe, surgical treatment should be carried out. 3. If patients have no motivation, vocal hygiene is recommended. However, much and lasting improvement cannot be expected from this line of treatment, because patients without motivation often do not follow the instructions. After puberty, no matter what treatment patients receive, their voice will improve in the ma-
.
jority of the patients. Instead no patient showed a deterioration of voice after puberty. One important point is the fact that about 12% of patients with vocal fold nodules do not show any improvement of their voice even after puberty. These patients may have another minor organic lesions such as shallow sulcus vocalis or may have some psychological problems. However, if the patient has no motivation, it is very difficult even to observe his/her glottis during phonation with the use of laryngostroboscope. Further investigation is necessary on this point.
References [1] J. Hirschberg, P.H. Dejonckere, M. Hirano, K. Mori, H.J. Schultz-Coulon, K Vrticka, Voice disorders in children, Ped. Otorhinolaryngol. (suppl) 32 (1995) 109 – 125.