The Effect of the Mother’s Participation in Therapy on Children with Vocal Fold Nodules

Abstract

Objectives:

Vocal fold nodules (VFN) are a bilateral epithelial thickening of the membranous vocal folds. In this study, children with VFN and their mothers took part in voice therapy. We then compared acoustic analyzes and subjective evaluations to those in previous literature to determine whether voice therapy is more effective for children with VFN when their mothers also take part in therapy.

Methods:

Children aged eight to 12 years who were diagnosed with bilateral VFN between January 2018 and January 2020 were included in this study. Participating children diagnosed with bilateral VFN were divided into two groups based on the wishes and cooperation of their families. Group 1 consisted of 16 patients; Group 2 included 17 patients. The children in Group 1 received voice therapy alone; children in Group 2 took part in therapy with their mothers. For all participants, the average fundemental frequency (F0), jitter percentages, shimmer percentages, maximum phonation time (MPT) and s/z ratios were measured. Pediatric voice handicap index (p-VHI) values were calculated as well.

Results:

The two groups’ measures pre-treatment and post-treatment were compared. Except for p-VHI, no significant difference was observed between the two groups. However, p-VHI post-treatment was significantly lower in Group 2 than in Group 1.

Conclusions:

Involving the families and even teachers of children with VFN in voice therapy can increase the effectiveness of therapy. The family’s involvement increases the child’s motivation in therapy. The mother’s presence during therapy, supporting the child or even doing the work with the child, can be a very important source of motivation for the child, who may already be tired from school and other activities. Thus, the mother’s involvement increases the child’s compliance with and interest in therapy.

Keywords

vocal fold nodules children voice therapy acoustic analysis subjective analysis

Introduction

Vocal fold nodules (VFN) are a bilateral epithelial thickening of the membranous vocal folds.¹ The nodules are located on the free edges of the junction between the anterior and middle third of the vocal fold and are generally symmetrical.^1,2 During speech, the first contact between the vocal folds occurs at the nodule, and air escapes in front of and behind the nodule (hourglass closure). This causes hoarseness in the voice.³

VFN are the most common cause of dysphonia in children, and their incidence in school-age children is 17% to 30%.^4,5 They are most common in children between the ages of five and 12.^1,4 The main cause of VFN in children is phonotrauma due to vocal abuse. VFN may develop due to excessive use of the voice or to vocal hyperfunction.^1,4 VFN are more common in children with siblings and are more likely to occur in younger siblings, especially boys, due to vocal abuse during sports activities. Children with attention deficit-hyperactivity disorder may experience phonotrauma caused by impulsive behaviours such as temper tantrums, yelling or screaming.² Laryngopharyngeal reflux, allergic rhinitis and dehydration have also been implicated in the development of VFN.^2,3 Although VFN are more common in boys than in girls,^3,4 persistent VFN occur more frequently girls.^2,3

Evaluating children with dysphonia requires a complicated approach that considers the possibility of vocal abuse and incorporates an environmental profile, an acoustic and perceptual assessment of the voice, an assessment of the impact of dysphonia on the patient’s quality of life, and a laryngoscopy and/or stroboscopy.^2,6 Once a diagnosis of VFN has been made, the cause is determined, and the goals of treatment are identified. Recent studies recommend the use of a laryngeal ultrasound to evaluate vocal nodules, especially in children who cannot tolerate laryngostroboscopy in the office environment.^1,6

The first treatment for VFN is conservative management (voice therapy).^2,7 Surgery and intralesional steroid injections are also used to treat selected cases.^2,3,7

The goal of voice therapy is to alter voice production patterns to reduce phonotrauma in daily life.² However, children may not adapt to voice therapy as easily as adults. Providing treatment at the child’s home and/or school can reduce anxiety, improve vocal quality and increase patient compliance. In the present study, the mothers of children with VFN took part in voice therapy with their children. Acoustic analyzes and subjective evaluations of the participants were then compared to those in previous studies to determine whether voice therapy with the patient’s mother is more effective than standard voice therapy for children with VFN.

Materials and Methods

The present study was approved by the Institutional Review Board and Ethics Committee of the Antalya Training and Research Hospital. All of the subject’s parents signed informed consent forms before participating in the study.

Patients

Children aged eight to 12 years old who were diagnosed with bilateral VFN between January 2018 and January 2020 were included in our study. This age group was chosen because children tolerate stroboscopy, are more likely than teenagers to comply with voice therapy, and do not experience pubertal changes affecting the larynx.

All participants in the study complained of dysphonia; the onset of vocal symptoms occurred two to 15 months before the study began. All participants underwent a complete otorhinolaryngological examination. Their vocal folds were assessed via a rigid laryngoscope with a 70° telescope, and the images were recorded on VHS tapes. All patients had bilateral nodules located at the junction of the anterior and middle third of the vocal fold.

Patients who had asthma, obstructive nasal or adenotonsillar pathology, vocal fold pathologies other than nodules, or who had previously received voice therapy were excluded from the study.

The participants consisted of children diagnosed with bilateral VFN and were divided into two groups based on the wishes and cooperation of their families.

Group 1, the standard therapy group, received voice therapy for the child; these children’s mothers were informed about and could observe the voice therapy.

Group 2, the mother-attended therapy group, received voice therapy sessions for the mother and child together; the mothers took part in therapy with their children.

In the first group, the mothers only supported the children’s vocal hygiene and therapy steps; in the second group, the mothers also took part in vocal hygiene and therapy and were even assigned therapeutic homework.

Each group initially included 25 children, for a total of 50 children with VFN. Twelve children (seven from Group 1 and five from Group 2) who did not regularly attend appointments were excluded. Two children from Group 1 and three from Group 2 who failed to do the therapeutic homework were excluded as well. Thus, 16 patients in Group 1 and 17 patients in Group 2 were included in the final analysis.

Voice Assesment

All participants’ spoken voices were recorded acoustically and spectrographically 1 week before voice therapy began and 1 month after voice therapy was completed. During the recording sessions, the patient was upright in a quiet room and was instructed in relaxation exercises by a language and speech therapist. The microphone, an Audio-Technica 2005 model dynamic microphone (Audio-Technica; Western Hemisphere, USA). Audacity (Audacity for Windows 98/ME/2000/XP), was placed 10 to 15 cm from the participant’s mouth, and the software program Audacity was used to record the participants’ speech.

The maximum phonation time (MPT) was determined by recording the longest /a/ that each patient could produce after deep inspiration. Next, a long /s/ and /z/ after deep inspiration were recorded. The s/z ratio was calculated by determining the proportion of the duration of the /s/ to that of the /z/. For the acoustic analysis, a 3 s flat /a/ tone was recorded. Praat software (version 2.5) was used for the acoustic analysis, which included the mean fundemental frequency (F₀), the mean intensity, the jitter percentage (%) and the shimmer percentage (%).

Subjective Assessment

All children responded to the Turkish Children’s Voice Handicap Index 10 (pVHI-10) 1 week before voice therapy began and 1 month after it was completed. The Turkish version of the pVHI-10, which was validated by Özkan et al,⁸ is used for a positive analysis of voice dysfunction.

Voice Therapy

Each participant received 40 minutes of voice therapy per week for an average of 8 weeks. They were advised to repeat the therapeutic exercises at home at least five times per day.

In first week of therapy, participants learned about vocal hygiene and reducing vocal abuse. They were instructed to improve vocal hygiene through behaviours such as increasing water consumption, reducing consumption of caffeinated and acidic drinks, ensuring adequate environmental humidity, taking quiet breaks throughout the day, avoiding speaking in noisy environments, standing face to face during conversation, avoiding speech during play and physical activity, and walking to the same room as a conversation partner.

In the second week, participants learned to engage in diaphragmatic breathing and were taught relaxation exercises for the chin, mouth and tongue. They learned vocal function exercises over the next 2 weeks, including a nasal /i/, vocal warm-up exercises, stretching and contraction exercises, and thick and thin lip and tongue trills.

In one exercise, participants said “molm” and observed the sensation of vibrations in the face. This was done at a normal speed and then accelerated and slowed down. Next, they said “molm” while sliding from a low pitch to a high pitch, then while sliding from a high pitch to a low pitch. Then the participants were asked to sing words melodically and sentences beginning with /m/, after which they sang sentences beginning with other sounds. In the final step, they applied the same technique to speech.

Statistical Analysis

Statistical analysis was made using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp, Armonk, NY). Data are expressed as mean ± SD. The normality assumptions were controlled by the Shapiro-Wilk test. In the comparisons between groups of parametric variables, Student’s t test was used. Paired Samples t tests were used to compare repeated measurements. A value of P < .05 was accepted as statistically significant.

A post hoc power analysis using the Gpower 3.1 revealed 88.2% statistical power with 0.05 alpha and dz = 0.693.

Results

The average age of the children included in the study was 10.7. Group 1 included 11 boys and five girls; Group 2 included 13 boys and four girls. No statistically significant difference was found between the baseline acoustic and aerodynamic parameters of the groups (Table 1).

Table 1.

Comparison of Pre-Therapy Results of Acoustic and Aerodynamic Analysis Between Groups.

	Group 1	Group 2	P
Fo	263.755 ± 23.811	257.925 ± 24.497	0.514
Jitter	1.062 ± 0.464	1.093 ± 0.435	0.854
Shimmer	8.859 ± 1.855	9.412 ± 1.527	0.380
MFZ	8.335 ± 1.842	8.366 ± 1.816	0.965
s/z	1.264 ± 0.205	1.281 ± 0.241	0.840
p-VHI	22.93 ± 4.38	23.4 ± 3.79	0.758

Note. Data are presented as mean ± SD. Student’s t test.

Table 2 shows the acoustic and aerodynamic parameters before and after treatment for both groups. Within both groups, F₀ and MFZ increased significantly, while jitter, shimmer, s/z and p-VHI decreased significantly (P < .001).

Table 2.

Comparison of Pre- and Post-Therapy Results of Acoustic and Aerodynamic Analysis in Each Group.

	Group 1		P	Group 2		P
	Before therapy	After therapy	P	Before therapy	After therapy	P
Fo	263.755 ± 23.81	270.338 ± 23.87	<0.001	257.925 ± 24.49	265.543 ± 24.69	<0.001
Jitter	1.062 ± 0.46	0.467 ± 0.25	<0.001	1.093 ± 0.44	0.352 ± 0.26	<0.001
Shimmer	8.859 ± 1.86	3.995 ± 0.83	<0.001	9.412 ± 1.53	3.915 ± 0.63	<0.001
MFZ	8.335 ± 1.84	9.987 ± 2.22	<0.001	8.366 ± 1.82	10.318 ± 2.41	<0.001
s/z	1.264 ± 0.21	1.111 ± 0.16	<0.001	1.281 ± 0.24	1.114 ± 0.13	<0.001
p-VHI	22.93 ± 4.38	14.2 ± 4.25	<0.001	23.4 ± 3.79	12.47 ± 4	<0.001

Note. Data are presented as mean ± SD. Paired Samples t test.

Table 3 shows the parameters pre- and post-treatment for both groups. Except for p-VHI, no significant difference was found between the two groups. However, p-VHI after treatment was significantly lower for Group 2 than for Group 1.

Table 3.

Comparison of the Difference Between Post-Therapy and Pre-Therapy.

	Group 1	Group 2	P
Fo	6.58 ± 4.75	7.62 ± 8.78	0.691
Jitter	−0.6 ± 0.41	−0.74 ± 0.45	0.359
Shimmer	−4.86 ± 1.6	−5.5 ± 1.55	0.282
MFZ	1.65 ± 0.83	1.95 ± 1.18	0.426
s/z	−0.15 ± 0.13	−0.17 ± 0.17	0.803
p-VHI	−8.73 ± 3.47	−12.93 ± 3.49	<0.001

Note. Data are presented as mean ± SD. Student’s t test.

Discussion

VFN are the most significant cause of dysphonia in children.^2,4,9 Although voice therapy is the first choice for treatment, there is no standard method of voice therapy. There is also no consensus in the literature regarding how long voice therapy should last.^2,9 The first aim of voice therapy is to prevent vocal abuse. Therefore, vocal hygiene is the first step in treatment. Vocal hygiene can reduce general symptoms via small but effective changes in the patient’s daily routine.^3,10,11

After vocal hygiene is introduced, voice therapy should begin. Voice therapy is very effective at reducing the size of lesions, resolving vocal problems and preventing relapses.⁸ In addition, unlike surgical methods, it does not cause any temporary damage to the vocal folds and does not involve any risk of complications. With voice therapy, nodules may regress and disappear within six to 12 weeks.⁴ However, voice therapy can be a long and difficult process that requires patience, making it very difficult for some children. In our study, we began voice therapy with 50 children with VFN; only 33 of those completed therapy.

At puberty, VFN may resolve spontaneously^2,3 since hyper-functional behaviours, such as excessive use of the voice, screaming and crying, decrease with maturity. However, since communication is very important for school-age children, VFN in children should not be left untreated in the hope that it will resolve spontaneously.^9,11 Children with VFN may worry about their peers’ reactions to their voices and may withdraw from social life as a result. In such cases, academic success, social skills, personal performance and even leadership skills can be affected by VFN.² Therefore, treatment should be started early.

Although Tezcaner et al¹ did not find a statistically significant difference in F₀ after voice therapy in children with VFN, they did observe significant differences in jitter, shimmer and NHR. Saltürk et al² showed that all measures improved significantly after resonance voice therapy in adult patients with VFN. In the present study, we observed statistically significant changes to jitter, shimmer and NHR after therapy in both groups. Improvement to VFN after therapy is measured by subjective tests as well as objective measurements. However, subjective and objective measures of improvement in VFN may not always correlate completely.¹²

It is important to involve the families and even the teachers of children with VFN in voice therapy to increase the effectiveness of therapy. Family follow-up can increase the child’s motivation^1,6 and sense of harmony. In the present study, mothers of children with VFN participated in voice therapy with their children. We expected that the mother’s presence would increase the child’s sense of safety and also support early detection of any technical problems related to therapy (misunderstandings, not knowing how to do the exercises at home, etc). Therefore, children in Group 2 received therapy with their mothers; the mothers were also asked to do the exercises at home. This was very effective: Children in the second group were more willing to take part in treatment and listened to instructions more carefully during therapy. However, there were no statistically significant differences between the two groups in post-therapy improvements to objective measures (Main frequency, jitter, shimmer, MFZ value). In other words, all participants who completed the therapy showed statistically significant improvements to the objective values, but there was no significant difference in the degree of improvement observed in the two groups.

However, the p-VHI-10 showed something different. All participants’ p-VHI-10 decreased after therapy, but these scores decreased significantly more for Group 2 than for Group 1. We attribute this to the positive impact of including the mothers in the voice therapy. In other words, while voice therapy improved objective measures for both groups, the participants’ perception of this improvement was greater for children who took part in voice therapy with their mothers. We therefore conclude that, especially for school-age children, it is very important for the mothers of children with VFN to take part in voice therapy, supporting their children and even performing the vocal exercises with them. A child who is already tired from school is more likely to perceive voice therapy with their mother as a game rather than a burdensome task. Furthermore, the mother’s involvement in voice therapy and participation in vocal exercises at home can increase the child’s motivation. Thus, the child’s compliance with and desire to engage in therapy increases.

This study is significant as it is one of the first demonstrating the positive effects of family participation in treatment on patients who struggle with treatment compliance, such as pediatric patients. The most important limitation of our study is the small sample size. In addition, in this study, both groups received 8 weeks of therapy. A second important limitation of this study is that it did not compare the effects of various durations of therapy.

Conclusion

VFN is the most common cause of childhood dysphonia. Although it often resolves spontaneously with puberty, it must be treated because of the social isolation it creates for the child. The first step in this treatment is voice therapy, and the family’s involvement in this therapy is important. Participation of the patient’s mother in voice therapy increases the workload of the speech therapist. However, the mother participation in voice therapy makes the child feel good. as our experience on this issue increases, we can determine how much the mother will participate in therapy

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

The present study was approved by the Institutional Review Board and Ethics Committee of the Antalya Training and Research Hospital (Date: 03/06/2020 No.7-22).

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Nevreste Didem Sonbay Yılmaz

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