Pediatric Vocal Cord Paralysis
What are the vocal cords?
The vocal cords (or folds) are two small muscles located within the larynx (voice box) that are responsible for voice production. They are found at about the level of the Adam’s apple (thyroid cartilage) in the neck. The vocal cords are very small (about 18mm in length for males and 11mm in length for females).
How is voice/speech produced?
Most of the time the vocal cords lie apart, forming a “V” shaped opening. During speech, the vocal cords come together and produce sound by vibrating. Movement of the lips and tongue change this sound to create individual speech sounds.
What is vocal cord paralysis?
Each vocal cord muscle is moved by a nerve called the recurrent laryngeal nerve (one on each side). If the nerve does not function properly, the attached vocal cord cannot move. This is vocal cord paralysis. This paralysis can result in either breathing or speech problems. Damage to one vocal cord causes a “breathy” voice, but rarely any breathing problems. Damage to both vocal cords causes severe noisy breathing (stridor), but the voice remains strong.
Vocal cord nodules are callous-like bumps on the vocal cords. They can form on one or both of the cords. They usually are located on the front 1/3 of the vocal cord, and range in size from a pinhead to a split pea. During normal speech, the vocal cords should press firmly together. However, if nodules are present the cords cannot close completely. Therefore, extra air escapes and the voice sounds hoarse and breathy as a result.
Are vocal cord nodules always the cause of a hoarse voice?
No, although vocal cord nodules are a common cause of persistent HOARSENESS, they are not the only cause. It is important to be evaluated by your doctor for any hoarseness present for more than four months.
What causes vocal cord nodules?
Any one or more of the following can contribute to the development of vocal cord nodules:
1) Misuse of the voice
- The use of an incorrect pitch, volume, or quality
- Inadequate breath support
- Excessive tension in the neck muscles when speaking
2) Abuse of the voice (the most common cause of vocal nodules in children)
- Excessive shouting, screaming cheering or crying
- Strained vocalizations (for example, sounds used to imitate animal noises or motors)
- Excessive loud talking
- Hard vocal attacks (starting words abruptly)
- Excessive coughing or throat clearing
3) Other factors
- Chronic (long standing) upper respiratory infections or allergies
- Exposure to smoking
- Reflux (stomach acid coming up the swallowing tube)
- Endocrine or Hormonal imbalance
- Personality or general adjustment of the child
How do vocal cord nodules develop?
Vocal abuse and misuse cause the vocal cords to close with excessive force (i.e. bang together). This may result in the formation of vocal nodules at the point of maximum contact. As the nodules begin to form, a slight reddening can be noted on the margin of the cord. This reddening is soon followed by a localized swelling or thickening on the edge of the cord. Finally, a definite nodule or bump develops and becomes harder and more fibrotic with time, just like a callous can form on your hand if you use a shovel without gloves.
Is there any pain associated with the development of vocal cord nodules?
At no time during the development of the nodules is there pain associated. The most common symptom of the presence of nodules is the breathy and hoarse quality of the voice. If you have pain, you should consult your doctor immediately.
How are vocal cord nodules treated?
The treatment of vocal nodules usually includes voice (or speech) therapy. This is best performed for at least 6months in twice-weekly 30 minute sessions.
Why is surgical removal alone usually not recommended?
It is important to understand that unless the causes of the vocal cord nodules are eliminated, the vocal cord nodules will most likely return no matter how often they are surgically removed. Surgery is not advisable for children with vocal cord nodules. (with rare exception)
What is the purpose of voice therapy?
The purpose of voice therapy is to reduce the vocal abuse or eliminate vocal misuse. It helps eliminate the causes of the nodules and teaches the child more efficient use of his/her voice.
What is involved with voice therapy?
The first step is to identify how the child uses his/her voice. The child must then be aware of these habits in order that they may be eliminated. It may be necessary to establish a new set of rules regarding the way in which the child may use his/her voice, and can include the following:
- Limit screaming, yelling, shouting, and long periods of singing
- Encourage the child to walk to where you can hear him rather than shout
- Replace abusive motor or animal sounds with less abusive sounds (sounds made with the lips for example, and not the voice)
- Replace throat clearing and dry coughing with hard swallowing and drinks of water (increase in fluid intake in general is helpful)
- Limit trying to talk over loud noises
- Rest the voice after loud periods occur, involving the child in a quiet, non-talking activity (for example, coloring)
How important is the family in the process?
Although continued follow-up by the otolaryngologist and speech pathologist are essential components of your child’s overall therapy program, the family’s participation and encouragement can mean the difference between success and failure in the treatment of vocal nodules.
What are some ways the family and people in the child’s environment can help?
These people can help to enforce the child’s new vocal behaviors with consistency. It is also important that the people in the child’s environment work to set a good example for the child.
How should these new vocal behaviors or “rules” be enforced?
Positive reinforcement is usually the most effective way. Praise him/her whenever you notice him practicing a new rule. Try not to nag about the bad habits; instead, point out the correct way to do it if you notice a slip. The child must learn that appropriate behavior gets good results and inappropriate behavior “never wins”.
Thomas M. Andrews
Dr. Andrews specializes in the medical and surgical treatment of ear, nose and throat disorders of children and adolescents. His accreditations include Florida State Medical License and Ohio State Medical License. He is also a board member of the National Board of Medical Examiners and American Board of Otolaryngology, Head and Neck Surgery