Consequences of Chronic Nasal Obstruction on the Laryngeal Mucosa and Voice Quality of 4- to 12-Year-Old Children

doi:10.1016/j.jvoice.2011.02.008

Journal of Voice

Volume 26, Issue 4, July 2012, Pages 488-492

https://doi.org/10.1016/j.jvoice.2011.02.008 Get rights and content

Summary

Introduction

Dysphonia affects 6% to 23% of children, and chronic nasal obstruction may participate in its pathophysiology.

Objectives

To study the effects of chronic nasal obstruction on children’s vocal quality.

Subjects and Methods

Two study groups were formed: nasal obstruction group (NOG), consisting of 60 children aged 4–12 years with important symptoms of chronic nasal obstruction; and a control group (CG), similar in gender and age range, consisting of healthy students without nasal, vocal, or auditory symptoms. The parents answered a questionnaire containing questions concerning their children’s vocal qualities. All the children were submitted to perceptual auditory analysis, acoustic vocal analysis, auditory acuity assessment (transient otoacoustic emissions and/or threshold tone audiometry), and videoendoscopic assessment (flexible laryngoscopy and rigid laryngoscopy).

Results

The groups were similar in age and gender. Parents reported a dysphonia rate of 76.6% in NOG and a vocal abuse rate of 68.3%. Eight children from NOG (13.34%) showed mild conductive hypoacusia. Laryngeal lesions were detected in 35 children from NOG (58%): inflammatory processes (n = 19), mucosal thickening (n = 10), nodules (n = 5), and cyst (n = 1). In children from the NOG were observed higher scores for the Grade, Roughness, Breathiness, Aesthenia, Strain, Instability (GRBAS) perceptual scale (P < 0.05), lower maximum phonation time values, and higher values to the s/z ratio, insufficient nasal resonance.

Conclusions

Relevant changes in perceptual auditory and acoustic vocal analyses and in the videolaryngoscopy were detected in children with nasal obstruction. These results showed the importance of the assessment of nasal obstruction in dysphonic children.

Introduction

Childhood dysphonia is relatively frequent (between 6% and 23%); and in most of the cases it arises from voice overuse and misuse.¹ The chronic use of inadequate vocal patterns fosters the development of laryngeal lesions on the vocal folds—mainly vocal nodules. Nonnodular laryngeal lesions, such as cysts, sulci, polyps, papillomas, granulomas, and the like, correspond to less than 10% of laryngeal diagnoses in children.2, 3

Nasal obstruction may play a role in the pathophysiology of voice disorders. Children’s voice with hypertrophy of tonsils results in hyponasality and a lower pitch. Cecil et al⁴ recorded lower fundamental frequency values on the voices of patients with chronic sinusitis when compared with healthy individuals. Meirelles,⁵ found changes upon examination of the nasal cavities of 113 patients, from a total of 208 with vocal nodules, as septal deviation, allergic rhinitis, bony changes to the nasal conchae, vasomotor rhinitis, tonsil hypertrophy, nasal polyposis, and Killian antrochoanal polyps. These authors emphasize the importance of identifying and treating nasal obstruction in children with dysphonia. The aim of the present study was to analyze the consequences of chronic nasal obstruction on the laryngeal mucosa and voice quality of children between 4 and 12 years of age.

Section snippets

Materials and methods

This study was approved by the Ethics in Research with Human Beings Committee of the Medical School of Botucatu—Unesp (protocol number 2933/2008). We gathered two study groups: CG—made up of 60 healthy children between 4 and 12 years of age, chosen at random from three public schools of the city of Botucatu (São Paulo). We excluded those children with nasal, vocal, or auditory symptoms, with cleft lip and palate, with genetic syndromes, and also those with a past of tracheal intubation or

Results

The groups were similar in gender and age: CG (31 males [Ms] and 29 Females [Fs]) and NOG (35 M and 25 F). The parents reported dysphonia rates of 76.6% in NOG children and 68.3% of frequent vocal abuse, without a predominance of one age range over the others (P > 0.05). Nasal endoscopic exams revealed adenoid and palatine tonsil hypertrophy as the main cause for nasal obstruction in all of them. The association with allergic rhinitis was observed in 28 children. Videolaryngoscopy showed numerous

Discussion

In the present study, information from the parents pointed to dysphonia rates of 76%, much higher than what has been published by other authors (between 6% and 24%),¹ indicating a possible participation of nasal obstruction in the origin of the vocal symptoms. However, the adequate interpretation of these results requires caution because these differences can be associated to the data collection method used in the different studies, peaking with the methodological failures. When the analyses

Conclusion

Relevant changes in vocal acoustic parameters and in the videolaryngoscopy were detected in children with nasal obstruction. These results showed the importance of the assessment of nasal obstruction in dysphonic children.

Acknowledgments

This study received financial support by Fapesp and CnPQ.

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Other researchers1 subdivide children into two groups: children and small children, considering average MPTs of 8.95 seconds and 7.5 seconds, respectively. It is important to consider the MPT results by age range, due to the neuromuscular development during the child's growth; so one can establish reliable comparisons, applicable in the clinical practice.2,33 Other authors suggest7 that an increase in the MPT may be possible after several emissions performed with visual support and emphasize the importance of implementing verbal instructions for the children with the purpose of improving their performance in this activity that requires abstraction.
Literature presents controversial maximum phonation time values in children.
Verify and correlate the maximum phonation time of vowels /a, i, u/ and the body mass index of children.
Evaluation of 484 children, eutrophic and without dysphonia, aged from 4:00 to 7:11 years. Sampling: questionnaire, audiometric screening, auditory-perceptual evaluation of voice, and assessment of the body mass index. Data collection: measurement of the maximum phonation time of /a, i, u/. Descriptive statistics, t test, and multiple regression at 5% significance.
/a:/ = 3.77 seconds at age 4:00 years, 5 seconds at 5:00, 5.85 seconds at 6:00, and 7.5 seconds at 7:00 for boys, and 3.89 seconds, 4.89 seconds, 5.61 seconds, and 6.61 seconds for girls, respectively; /i:/ = 3.49 seconds at age 4:00 years, 4.96 seconds at 5:00, 5.72 seconds at 6:00, and 6.88 seconds at 7:00 for boys, and 3.49 seconds, 4.73 seconds, 5.41 seconds, and 6.63 seconds for girls, respectively; /u:/ = 3.64 seconds at age 4:00 years, 4.85 seconds at 5:00, 5.76 seconds at 6:00, and 7.08 seconds at 7:00 for boys, and 3.54 seconds, 4.73 seconds, 5.64 seconds, and 6.47 seconds for girls, respectively. There were no significant differences between genders, except for /a:/ at age 7:00 years. The correlations were not significant.
Maximum phonation time of /a, i, u/ increased with age and its value in seconds was approximately equal to the age in years. At the age 7:00 years, /a:/ from boys was longer. The body mass index did not show influence on the maximum phonation times.
Effects of Orthognathic Surgery on Voice Characteristics
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Orthognathic surgery not only corrects dentofacial deformities but also affects some vital structures involving voice production. The primary aim of this study was to analyze the effects of bimaxillary orthognathic surgery on voice characteristics of patients with class II and III skeletal deformities; the second aim was to evaluate possible associations among acoustic parameters, pharyngeal airway, and skeletal changes after surgery.
Using a prospective cohort study design, we enrolled a sample of patients who underwent bimaxillary orthognathic surgery in the university hospital between January 2018 and January 2019. Voice records and cone-beam computed tomography (CBCT) scans of the patients were acquired before surgery and 6 months after surgery. Pharyngeal airway volume, minimum cross-sectional area, hyoid bone position, and skeletal movements of the maxilla and mandible were assessed with Dolphin Imaging software using CBCT data as predictor variables. Acoustic analysis of voice samples (vowel/a/) were performed with Praat software as outcome variables. The within-group and between-group differences in data were analyzed using paired-sample and independent-sample t tests. The degree of relationship between voice and CBCT parameters was assessed using Pearson correlation and multiple regression analysis.
The study sample comprised 33 patients; 14 patients had class II skeletal deformity and 19 patients had class III skeletal deformity. Orthognathic surgery in both patients with class II and III skeletal deformities resulted in significant changes in all the voice parameters (All P < .05). Only patients with class II skeletal deformity showed significant changes in airway parameters (increase; all P < .001) and hyoid bone positions (anterosuperior movement; P = .001 and P = .008, respectively). Multiple regression analysis showed that some specific structural changes significantly affected some specific acoustic parameters.
Bimaxillary orthognathic surgery significantly changed the acoustic parameters of voice in patients with class II and III skeletal deformities. Some of the structural changes were significantly associated with some of the acoustic parameters.
Investigating the Effects of Glottal Stop Productions on Voice in Children With Cleft Palate Using Multidimensional Voice Assessment Methods
2016, Journal of Voice
The aim was to investigate the effects of glottal stop productions (GS) on voice in children with cleft palate using multidimensional voice assessment methods.
This is a prospective case-control study.
Children with repaired cleft palate (n = 34) who did not have any vocal fold lesions were separated into two groups based on the results of the articulation test. The glottal stop group (GSG) consisted of 17 children who had GS. The control group (CG) consisted of an equal number of age- and gender-matched children who did not have GS. The voice evaluation protocol included acoustic analysis, Pediatric Voice Handicap Index (pVHI), and perceptual analysis (Grade, Roughness, Breathiness, Asthenia, Strain method). The velopharyngeal statuses of the groups were compared using the nasopharyngoscopy and the nasometer.
The total pVHI score and the subscales of the pVHI were found to be significantly higher in the GSG. The F0, jitter, and shimmer were found to be numerically higher in the GSG with the difference being statistically significant in jitter (P < 0.05). Audioperceptual analysis revealed a difference in overall voice quality and roughness between the groups. Greater incidence of significant velopharyngeal insufficiency and higher nasalance scores were found in the GSG (P < 0.05).
These results may indicate that the vocal quality characteristics of children with GS differ from children who do not have this type of production. It is suggested that children with cleft palate who have GS should receive a comprehensive speech and language pathology intervention including voice therapy techniques.
Auditory-perceptual analysis of voice in abused children and adolescents
2015, Brazilian Journal of Otorhinolaryngology
Citation Excerpt :
Genetic and environmental components influence the onset of vocal symptoms in different ways: the genetic effect is moderate, while the environmental effects are the more important factors in the onset of dysphonia.18 The causes of dysphonia include premature birth;19 nasal obstruction;20 allergic pulmonary reactions, such as asthma and bronchitis; gastroesophageal reflux; auditory symptoms;16 and sleeping problems.21 The main cause, however, is vocal abuse by children, as indicated by studies with dysphonic children (90.3%,22 45.2%,23 and 54.67%24).
Abused children and adolescents are exposed to factors that can trigger vocal changes.
This study aimed to analyze the prevalence of vocal changes in abused children and adolescents, through auditory-perceptual analysis of voice and the study of the association between vocal changes, communication disorders, psychiatric disorders, and global functioning.
This was an observational and transversal study of 136 children and adolescents (mean age 10.2 years, 78 male) who were assessed by a multidisciplinary team specializing in abused populations. Speech evaluation was performed (involving the aspects of oral and written communication, as well as auditory-perceptual analysis of voice, through the GRBASI scale). Psychiatric diagnosis was performed in accordance with the DSM-IV diagnostic criteria and by applying the K-SADS; global functioning was evaluated by means of the C-GAS scale.
The prevalence of vocal change was 67.6%; of the patients with vocal changes, 92.3% had other communication disorders. Voice changes were associated with a loss of seven points in global functioning, and there was no association between vocal changes and psychiatric diagnosis.
The prevalence of vocal change was greater than that observed in the general population, with significant associations with communication disorders and global functioning. The results demonstrate that the situations these children experience can intensify the triggering of abusive vocal behaviors and consequently, of vocal changes.
Crianças e adolescentes vítimas de maus tratos estão expostas a fatores que podem desencadear alterações vocais.
Analisar a prevalência de alteração vocal nesta população realizando análise perceptivo-auditiva da voz e estudar a associação entre alteração vocal, transtornos da comunicação, transtorno psiquiátrico e funcionamento global.
Estudo observacional e transversal. Participaram 136 sujeitos, com idade média de 10,2 anos, atendidos por equipe multidisciplinar especializada no tratamento ambulatorial de vítimas de maus tratos. Foi realizada avaliação fonoaudiologia (aspectos da comunicação oral e escrita e análise perceptivo-auditiva da voz a qual foi feita por meio da escala GRBASI). O diagnóstico psiquiátrico foi dado de acordo com os critérios diagnósticos da CID-10 e aplicação do K-SADS; o funcionamento global foi avaliado por meio da escala C-GAS.
A prevalência de alteração vocal foi de 67,6%, dos pacientes com alteração vocal, 92,3% apresentaram outros transtornos da comunicação. A alteração vocal está associada a um prejuízo de sete pontos no funcionamento global e não apresentou associação com transtorno psiquiátrico.
A prevalência de alterações vocais encontrada foi maior do que a observada na população geral, com associações significantes com transtornos da comunicação e funcionamento global. As situações que estas crianças vivem podem intensificar o desencadeamento de comportamentos vocais abusivos e consequentemente de alterações vocais.
Effect of adenoid hypertrophy on the voice and laryngeal mucosa in children
2013, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
According to Mora et al., tonsil or adenoid enlargement causes turbulence to the air passing through the resonator canal, resulting in air flow resistance, which can impact the regular utterance of voice, resulting in dysphonia and hyponasal voice [19]. Lábio et al., reported that the videolaryngoscopy exam of children with nasal obstruction revealed the building up of secretion on the vocal folds, hyperemia, congestion, and even laryngeal lesions, seen in 58% of the children in their study, such as mucosal thickening and vocal nodules [13]. This agree with our results as 32.5% of our patients suffer from vocal fold lesions (vocal fold congestion, thickening of mucosa and vocal nodules).
The adenoids, or pharyngeal tonsils, are lymphatic tissue localized at the mucous layer of the roof and posterior wall of nasopharynx.
Dysphonia defined as perceptual audible change of a patient's habitual voice as self judged or judged by his or her listeners.
The diagnosis of dysphonia relies on clinical judgment based on phoniatric symptoms, auditory perceptual assessment of voice (APA) and full laryngeal examination.
Our study was conducted to evaluate the effect of adenoid hypertrophy on voice and laryngeal mucosa. The study sample composed of sixty children, forty of them had adenoid hypertrophy (patient's group) and twenty healthy children (control group). Patient's group composed of 17 boys (42.5%) and 23 girls (57.5%), while control group consists of 8 males (40%) and 12 females (60%). All patients and control group subjected to history taking, clinical examination, lateral soft tissue X-ray on the nasopharynx, APA based on the modified GRBAS scale and full laryngeal examination. The data are collected and analyzed statistically by using software SPSS.
Our results showed that there is a significant association between adenoid hypertrophy and, degree of dysphonia, leaky voice, pitch of voice and laryngeal lesion.
Adenoid hypertrophy did not associate with loudness of voice, as well as character (irregular, breathy and strained). Laryngeal lesions were detected in thirteen children from patient group (32.5%): nodules (n = 6), thickening (n = 5), congestion (n = 2), while one child only out of 20 children of the control group had congestion (5.0%).
Our results showed the importance of the assessment of voice and laryngeal examination in patients with adenoid hypertrophy, also treating the minimal mucosal lesions that results from adenoid hypertrophy should be taken in consideration.
Dysphonia in children
2012, Journal of Voice
Citation Excerpt :
This condition demands an increase in subglottic pressure and effort in phonation. Some authors registered important alterations in the auditory-perceptual vocal parameters and in the acoustic measures of patients with tonsils hypertrophy, in addition to an improvement in the acoustic parameters such as the resonance after surgery of tonsils, confirming the influence of respiratory disturbs on the phonation.19,20 Although not frequently reported by the parents of the pediatric subjects of this study (3.6%), gastroesophageal symptoms should be included in the care protocols for child and adult patients with dysphonias because the reflux laryngitis can be associated with several laryngeal lesions such as inflammation, pachydermia, mucosal thickness, nodules, and vocal polyps.21,22
Vocal symptoms are common among the pediatric population and are often caused by vocal abuse. Laryngoscopy is essential for their diagnosis because it helps differentiate several laryngeal lesions, leading to a decision for suitable treatments considering each case.
This study aims to present the clinical characteristics, and the laryngoscopic diagnosis of a dysphonic child population.
The parents of 304 children, aged from 4 to 18 years and presenting prolonged hoarseness, answered a questionnaire about their children’s voice, and all children were subjected to videolaryngostroboscopy.
Male children aged from 7 to 12 years (64%) were predominant. Vocal abuse (n-162) and nasal obstruction symptoms (n-10) were the most frequent associated symptoms. The vocal symptoms had a chronic evolution (over 1 year) and were reported by most parents (n-200). The most commonly diagnosed lesions in the laryngoscopic exams were vocal nodules (n-175) and epidermal cysts (n-47). Furthermore, there was an association of some lesions, especially minor structural alterations.
In the present study, dysphonia occurred mainly in children aged from 7 to 12 years, predominantly males. Vocal abuse and nasal obstruction symptoms were frequently reported. Vocal nodules and cysts were the most commonly diagnosed laryngeal lesions in the laryngoscopic exams.

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: Financial support—Fapesp/Capes.

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Consequences of Chronic Nasal Obstruction on the Laryngeal Mucosa and Voice Quality of 4- to 12-Year-Old Children

Summary

Introduction

Objectives

Subjects and Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Acknowledgments

Int J Pediatr Otorhinolaryngol

J Voice

J Voice

J Voice

J Voice

The prevalence of laryngeal pathology in a treatment-seeking population with dysphonia

Laryngoscope

Childhood voice disorders: ambulatory evaluation and operative diagnosis

Clin Pediatr (Phila)