Dysphonia in childhood. Experience of personal observations

Relevance

The human voice is a unique physiological, acoustic, and biosocial phenomenon. As a social signal, it acquires significance from the very first days of a child's life. Infants can distinguish their mother's voice from those of other people. A study of brain activity using magnetic resonance imaging in healthy children, upon the utterance of meaningless words by biological mothers and unfamiliar women, demonstrated that the mother's voice elicits the greatest activity in the auditory areas of the brain compared to the voices of other women [1].

The voice can be considered a stimulus that fosters the development of emotional intelligence and the child's social function as an individual. It is important to understand that the voice is a fundamental component for the successful and comprehensive development of the child, as well as for the formation of their character and specific behavioral traits [2].

The voice ensures the intelligibility, expressiveness, and emotionality of speech – it is not only a means of communication but also a professional tool for many people: teachers, singers, announcers, doctors, radio hosts, etc. Consequently, a voice defect can become an obstacle to pursuing a chosen profession, which is extremely important in the vocational guidance of adolescents [3].

The phonation mechanism in a child differs from that in an adult, which is associated with age-related anatomical features of the larynx and the disproportionate development of the vocal apparatus. In children, the larynx is positioned higher, is smaller in size, and has a narrower lumen compared to the adult larynx. The epiglottis in the first 2-2.5 years of life has a gutter-like shape with inwardly curved edges. Gradually, this cartilage increases in size, flattens (remaining slightly concave in adults), and acquires a greater angle of inclination. Short pediatric vocal folds – anatomically and functionally immature – are more susceptible to inflammatory and traumatic damage. Other features of the "infantile" larynx include an elastic framework and underdevelopment of the thyroarytenoid muscle [4].

Due to the uneven growth of voice-producing organs, the child's voice undergoes changes. The tonal range of the voice in girls and boys from seven to ten years is approximately the same, spanning about one octave in the interval "D1" – "D2". By age 14, the interval expands: from "C1" to "F2". By the end of puberty, the vocal range "matures" to two octaves, i.e., it approaches the vocal range of an adult (two to three octaves).

The mechanism of phonation also changes during ontogenesis. From birth to 7 years, the falsetto mechanism of phonation predominates, where the vocal folds vibrate not along their entire width but only at their free edge. In this process, the dominant role is assigned to the cricothyroid muscle, while other laryngeal muscles participate only indirectly in voice production. The thyroarytenoid, or vocalis, muscle begins to form between the ages of 7-12 years and develops until 19-20 years of age, which accounts for the gradual transition from falsetto to the chest type of voice production [5].

Disorders of voice timbre, changes in its pitch or loudness compared to norms for a specific age and sex lead to a disruption of the complex voice production process, termed "dysphonia". The prevalence of dysphonia in children is high. According to epidemiological studies, this rate ranges from 6 to 23% [6, 7, 8].

Overall, dysphonias are among the most common conditions in children of all ages, with voice disorders occurring more frequently in boys than in girls. Children with voice timbre disorders such as hoarseness, huskiness, or vocal weakness often experience difficulties in adequately expressing their thoughts and feelings. This leads to the formation of low self-esteem and manifests as psychosocial problems due to poor communication skills. As adults, they continue to suffer from the discomfort caused by their "unhealthy" voice, seek additional treatment, thereby increasing the economic burden on healthcare [9].

According to one observational study, the most frequent predictors for the development of voice disorders in children and adolescents include prolonged exposure to noisy environments (kindergarten, school), strained and loud talking (shouting, screeching, crying), common colds, smoking and exposure to secondhand smoke, forced vocalization (singing), emotional situations, sports involving vocal strain, as well as surgical interventions, including those not on the larynx but performed under intubation anesthesia. Dysphonias are often accompanied by conditions and symptoms such as asthma and bronchitis, gastroesophageal reflux (GER), allergic rhinitis, chronic tonsillitis, adenoid hypertrophy, sneezing, nasal congestion and rhinorrhea, headaches, ear noise and pain, and hearing loss [10].

The main manifestations of dysphonias are a change in voice timbre, most often persistent hoarseness, or rapid vocal fatigue after excessive vocal load, when the child wakes up in the morning with a clear voice but becomes hoarse or husky by evening. Among the numerous laryngeal pathologies, vocal fold nodules are considered the most common in childhood. Other causes of voice disorders in children include polyps, vocal fold cysts (epidermoid and mucosal), edematous laryngitis, and functional dysphonia. In approximately 27-41% of children, the cause of their dysphonic voice is congenital pathology – vocal fold sulcus, laryngeal web, congenital vocal fold paralysis [10].

According to Serbian researchers, most voice disorders occur in children aged 5 to 10 years, when intensive peer communication begins. It is believed that precisely during this period, improper use of the vocal apparatus's capabilities and excessive vocal loads create the groundwork for the development of persistent dysphonia [11].

It is important to understand that voice disorders in children are not a temporary problem but require close attention from parents, teachers, and doctors, high-quality diagnosis considering age-related characteristics, as well as the selection of optimal treatment aimed at rehabilitating vocal function and creating conditions for the child's comprehensive development.

Objective

The aim of this study was to assess the nature of laryngeal pathology in children and adolescents at an outpatient appointment with an otorhinolaryngologist-phoniatrician and to analyze factors influencing the effectiveness of rehabilitation measures.

Material and Methods

This was an observational clinical study conducted from January 2023 to May 2025 at the multidisciplinary medical center "N.U.Z. Hospital 'Clinic of Modern Medicine'" (Director – S.A. Ivanchina), which houses an otorhinolaryngology office equipped with endoscopic equipment necessary for the phoniatric examination of patients with voice disorders. The inclusion criteria were: 1) patient age – children and adolescents aged 5 years to 17 years 11 months; 2) any laryngeal diseases in children leading to a persistent change in voice timbre and intensity. Patients with acute laryngeal pathology developing against the background of an acute respiratory infection (acute laryngitis) were excluded from the study.

According to the proposed criteria, 97 children and adolescents aged 5 to 17 years inclusive were evaluated during the specified period. The mean age was 11.6 ± 2.0 years. The comprehensive patient examination included history taking, assessment of complaints, voice status, quality of life, and examination of all ENT organs (nasal cavity, nasopharynx, oropharynx, larynx and laryngopharynx, external auditory canals, and tympanic membranes), performed using endoscopic technique. Optical laryngeal endoscopy in children aged 12 years and older was performed using a "Karl Storz" telescopic laryngoscope with a diameter of 10 mm and 90° side-view optics. In children under 12 years of age, a "Karl Storz" telescopic laryngoscope with a diameter of 7 mm and 70° side-view optics or a fibrorhinopharyngolaryngoscope from the same manufacturer with a diameter of 1.6 mm was used (the latter method was intended for cases where laryngoscopy with a rigid endoscope was not feasible). During laryngoscopy, the larynx was examined under both constant and pulsed light. A portable laryngostroboscope μ-PULSAR40 was used for stroboscopy.

Voice quality was assessed subjectively using the internationally accepted GRBAS scale. The specialized Voice Handicap Index (VHI) questionnaire was used to obtain information on quality of life.

As the diagnosed laryngeal pathology was diverse, various rehabilitation methods were employed during patient follow-up: inhalation therapy, physiotherapeutic procedures, breathing exercises, voice therapy, and surgical interventions. The criteria for therapy effectiveness were improvement in voice quality or complete restoration of its sonority and intensity, dynamics of GRBAS and VHI scores, and changes in the laryngoscopic and stroboscopic picture of the larynx.

Statistical analysis was performed using IBM SPSS Statistics V27 software, employing Student's t-test (for quantitative parameters with normal distribution), Pearson's chi-square test (for comparing qualitative parameters), and the Wilcoxon W-test for assessing differences between two related groups with non-normal distributions. A p-value < 0.05 was considered the threshold for statistical significance.

Results and Discussion

The distribution of patients by condition and diagnosed laryngeal pathology was as follows: voice mutation – 48 adolescents aged 12-15 years (36 boys, 12 girls); vocal fold nodules – 37 children aged 5 to 14 years (boys – 34, girls – 3); unilateral vocal fold cyst – 2 children (a 14-year-old girl, a 17-year-old boy); unilateral vocal fold polyp – 1 (15-year-old girl); unilateral neurogenic vocal fold paralysis – 5 adolescents (4 girls aged 12-14 years, a 13-year-old boy); bilateral myogenic vocal fold paresis – 1 (12-year-old girl); laryngeal contact granuloma – 1 (13-year-old girl); chronic edematous laryngitis – 2 (6-year-old girl, 9-year-old boy). Overall, voice mutation (49.5%), currently regarded as an age-related functional state of the larynx, and vocal fold nodules (38.1%) predominated in the morbidity structure. The remaining pathologies accounted for no more than 12.4%. Furthermore, the majority of pediatric and adolescent patients were boys – 73 patients (75.3%), with girls numbering 24 (24.7%).

It is noteworthy that in most cases, the initiators of the consultation were not the child's parents, but vocal coaches, general education school teachers, preschool educators, or pediatricians from the clinics where the child has been monitored since birth. In five cases, children were referred by allergists and pulmonologists; these were patients with allergic rhinitis and bronchial asthma. Four children were referred on the recommendation of surgeons, having undergone surgery for congenital heart disease (heart defect, 3 children) and malignant thyroid tumor (1 girl). However, there were also those who applied independently, and on the child's own initiative. These were adolescents with chronic dysphonia, apparently originating in early childhood. Parents typically become accustomed to the peculiarities of their child's voice. But upon reaching 13-14 years of age, adolescents become more sensitive to the opinions of others and react painfully to comments regarding their voice quality.

The majority of children seeking medical help (79.4%) were categorized as "singers," as they regularly engaged in vocal and choral singing in music schools or children's studio groups under the guidance of vocal coaches. Of these, 70.4% had more than two years of singing experience. Another adolescent, a 15-year-old girl, participated in a theater studio. The remaining children had no professional voice training or vocalization skills.

Among the concomitant pathologies, the most prevalent were: pharyngeal tonsil hypertrophy (76 children, 78.4%), allergic rhinitis (23, 23.7%), chronic tonsillitis and palatine tonsil hypertrophy (46, 47.4%), and confirmed gastroesophageal reflux (12, 12.4%).

The primary complaint of patients was a change in timbre in the form of hoarseness, huskiness, or roughness in the voice (100% of observations). Marked hoarseness was mainly characteristic of children with neurogenic laryngeal paralyses, vocal fold nodules, and chronic edematous laryngitis. "Singing" children reported rapid vocal fatigue after vocal load and towards the evening, difficulties when singing piano (quietly), and the onset of cough after vocalization. Adolescents with voice mutation complained of voice instability, breaks and "voice cracking into falsetto," changes in vocal range with a shift towards lower frequencies, and rarely – pain in the laryngeal area and a sensation of spasms in the pharynx, but only during vocalization. However, these complaints primarily concerned adolescent boys. Girls tolerated the mutation period much more easily but also noted a narrowing of their vocal range.

Significant differences in the GRBAS score were found between boys and girls during voice mutation. The GRBAS score was significantly higher in boys compared to girls, amounting to 3.7 ± 0.9 and 2.8 ± 1.0 points, respectively (p=0.002040). Comparison of GRBAS scores in other laryngeal conditions revealed no significant gender differences. For vocal fold nodules, voice quality in boys was rated at 5.1 ± 1.2 points, and in girls at 4.8 ± 1.4 points (difference not significant, p=0.0550168), with an average score of 4.9 ± 1.3 points. In vocal fold paralyses, the score ranged from 3.6 to 8.3 points; for polyps and vocal fold cysts – from 2.7 to 4.3 points, which was significantly lower compared to other laryngeal pathologies, p < 0.05. The highest GRBAS values were recorded in two children with chronic edematous laryngitis: (11.0 and 9.9 points, respectively) and in a girl with laryngeal contact granuloma – 12 points. Due to the small sample size, mean GRBAS values for nodular laryngeal formations, chronic laryngitis, and vocal fold paralyses were not calculated.

The worst quality of life indicators were demonstrated by children with myogenic and neurogenic vocal fold paralysis; their VHI scores ranged from 64 to 88 points, those with chronic laryngitis (61 and 66 points), and with laryngeal contact granuloma (72 points). In children with nodular vocal fold formations, the score was 26.1 ± 13.1, and in mutation, it generally did not exceed 25 points, but was significantly higher in boys (16.3 ± 6.8 points) than in girls (11.3 ± 3.7 points), indicating more pronounced manifestations of the mutational period in male adolescents. Regardless of the laryngeal pathology, the dominant statements in the VHI questionnaire were those emphasizing a more pronounced impact of dysphonia on the child's general physical condition rather than on their functional and emotional status. Thus, over 83.5% of children assigned the highest scores to statements such as: "I have to use a great deal of effort to speak," "My voice problem upsets me," "People have difficulty hearing me in a noisy room," "My voice problem causes me to lose income," "I tend to avoid groups of people because of my voice problem." It should be noted that the results obtained from surveying the children often differed from those obtained from interviewing their parents. Parents either did not notice the problems arising from the voice disorder or did not pay sufficient attention to them, which explains the pattern of targeted referral to a phoniatrician by educators and medical professionals.

The endoscopic and stroboscopic findings of the larynx in all examined patients fully corresponded to the pathology and served as the primary criterion for diagnosing not only the underlying disease (laryngeal pathology) but also the aforementioned concomitant pathologies. The importance of fiberoptic laryngoscopy in children under 12 years of age must be emphasized, as anatomical features of the larynx – a narrow lumen, gutter-shaped epiglottis, pronounced gag reflex, as well as the child's behavioral response to manipulations – create obstacles for visualizing the glottic region. In our study, fiberoptic laryngoscopy was required in 15 cases, including two children over 12 years old. Nevertheless, in our practice, we always attempted to begin with telescopic laryngoscopy, which, unlike fiberoptic laryngoscopy, does not require anesthetic support, but with mandatory preliminary patient preparation involving an explanatory conversation about the nature of the procedure and its demonstration using illustrations and a simulator.

Among the variety of diagnosed laryngeal diseases, two clinical cases distinguished by their rarity should be noted: a contact granuloma in a 13-year-old girl and chronic polypoid-edematous laryngitis, better known as Reinke's edema, in a 6-year-old girl.

Contact granuloma results from trauma to the mucosa covering the vocal process of the arytenoid cartilage. In childhood, contact granuloma accounts for no more than 3–7% of all benign laryngeal neoplasms. The main mechanisms of its development are considered to be intubation trauma (50–70% of cases), repetitive compensatory hyperadduction of the mobile vocal fold in laryngeal paralyses, GER (in which case the disease in children is often asymptomatic), chronic cough (e.g., in whooping cough, asthma), and phonotrauma (chronic shouting, cheerleading, certain sports involving forced speech techniques) [12]. Contact granuloma develops slowly, but in our case, hoarseness in the adolescent girl appeared almost immediately after excessive vocal load during a school play rehearsal.

The second observation concerns a 6-year-old girl with a history of prolonged, four-year hoarseness and a rough voice. Regarding the dysphonia, the child's parents had repeatedly consulted a pediatrician and an otorhinolaryngologist locally, but no specific laryngeal examination had been performed. Fiberoptic laryngoscopy revealed cushion-like edema of both vocal folds with preserved mobility during phonation, consistent with the picture of Reinke's edema – a specific type of hyperplastic laryngitis more characteristic of smoking adults [13]. In childhood, the most common causes of Reinke's edema are chronic cough and the use of a hard glottal attack in speech. In our case, the girl was diagnosed with clinically significant, untreated GER, which apparently contributed to the development of the polypoid-edematous form of chronic laryngitis. Proof of our assumption was the complete regression of the inflammatory process in the larynx and restoration of voice sonority following anti-reflux therapy.

The treatment strategy for our patients was determined by the nature of the pathology and typically involved a combination of measures. For nodular vocal fold formations and chronic laryngitis, anti-inflammatory, absorbable therapy in the form of inhalations and voice therapy were prescribed. For laryngeal paralyses, given the chronicity of the condition (over 6 months), the primary treatment method was long-term voice therapy with a good functional outcome. Only in one case, involving a 15-year-old girl with a disease duration of 14.5 years (unilateral vocal fold paralysis developed as a complication of cardiac surgery), was a two-stage surgical approach necessary, comprising injection medialization of the affected vocal fold (the functional effect lasted no more than 8 months), followed by endoscopic laryngoplasty using autologous cartilage. Currently (the girl is now 17 years old), the functional characteristics of the voice do not satisfy the patient, hence a third surgical stage – type III thyroplasty with a titanium implant – is planned.

In cases of voice mutation, most children (42, 87.5%) did not experience significant problems from the voice changes and range fluctuations, and vocalists were not exempted from singing lessons. Such adolescents required dynamic observation and were invited for follow-up examinations every 3 months. In 12.5% of cases (all boys), the mutation was accompanied by pronounced manifestations such as hoarseness, voice breaks, and painful sensations in the laryngeal area. This was typically associated with a narrowing of the tonal range to less than one octave, constituting valid grounds for temporary suspension from singing for several months.

The assessment of therapy effectiveness was based not only on the endoscopic picture of the larynx but also on the dynamics of GRBAS and VHI parameters. Regarding the functional state of the larynx and voice, the effect was considered "good" with GRBAS values of 0-1 point and VHI scores of 0-12 points. The absence of dynamic changes in these parameters was evaluated as an "unsatisfactory result." 82 out of 97 patients returned for follow-up examinations. Ten children with nodular vocal fold formations and 5 children with voice mutation were non-compliant with dynamic observation. The therapy effect was rated as "good" in 83.3% of children with nodular laryngeal formations (25 out of 30), in 5 out of 6 children with neurogenic and myogenic vocal fold paralyses, and in two cases of chronic laryngitis. The adolescent girl with laryngeal contact granuloma was referred for surgical treatment.

Conclusions

1. Among the causes of childhood dysphonia, voice mutation—considered a natural functional age-related state of the larynx rather than a pathology—and vocal fold nodules predominate. Rare clinical cases of dysphonia development in children include contact granuloma and chronic polypoid-edematous laryngitis (Reinke's edema). Voice disorders are most frequently encountered in boys.

2. In most cases, the initiators of the referral to a phoniatrician are not the child's parents, but vocal coaches, teachers and educators of general education institutions, physicians of other specialties, or the child themselves. This fact is explained by parents becoming accustomed to the peculiarities of their child's voice, thereby either not noticing problems associated with voice disorders or failing to give them due attention.

3. For voice disorders in childhood, various rehabilitation methods can be employed (inhalation therapy, physiotherapeutic procedures, breathing exercises, surgical interventions); however, in most cases, voice therapy remains the leading method. The effectiveness of rehabilitation measures depends entirely on patient compliance.