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Effects of Voice Therapy in School-Age Children

Article · September 2013

DOI: 10.1016/j.jvoice.2013.06.007 · Source: PubMed

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Effects of Voice Therapy in School-Age Children
€ u
Ozg € l Akin Şenkal and Mu
€ zeyyen Çiyiltepe, Adana, Akdeniz, Turkey

Summary: Objectives. To assess the overall efficacy of voice therapy for dysphonia in school-age children in two
different cities in Turkey.
Study Design. Retrospective cohort study.
Methods. Ninety-nine outpatients aged 7–15 years with persistent hoarseness for at least 2 months as a primary symp-
tom. Ratings of the Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) scale, s/z ratio, and maximum pho-
nation time (MPT). Voice therapy outcome data collected on three types of voice therapy (physiological, hygienic, and
symptomatic).
Setting. Outpatient clinics in university hospitals in two different cities in Turkey.
Results. Voice therapy improved voice quality as assessed by an observer according to GRBAS rating system
(P < 0.0001). All the subjects demonstrated varying degrees of hoarseness (G1–G3) and strained (S1–S3) voices. Vary-
ing degrees of roughness (R1–R3) and breathiness (B1–B3) were also noted. In general, changes to the value of the
grade (the measure of the overall degree of voice deviance) were statistically significant (t ¼ 8.3; P < 0.0001) before
and after therapy. Significant changes were found in the s/z ratio when the values were compared before and after ther-
apy sessions (t ¼ 11.08; P < 0.0001). Changes in MPT were statistically significant for all types of voice therapy
(P < 0.0001).
Conclusions. Vocal nodules were the main cause of the school-age children’s voice problems, accounting for 62.6%
of the cases. Different types of voice therapy techniques could be used in school-age children. Many of these techniques
can successfully restore the normal voice. However, in this study, all subjective voice ratings such as GRBAS, s/z ratio,
and MPT statistically changed by symptomatic voice therapy techniques. Symptomatic voice therapy was found to be
a successful method of therapy.
Keywords: Voice–Child–Voice therapy–Evidence-based practice.

HOARSENESS IN SCHOOL-AGE CHILDREN
Hoarseness (dysphonia) is defined as a disorder characterized
by altered voice quality, pitch, loudness, or vocal effort that im-
pairs communication or reduces voice-related quality of life.1
There are various causes of voice problems in childhood
(Table 1). Hoarseness has a lifetime prevalence of 6.6% (per-
cent of people affected at a given point of time). Hoarseness
may affect all age groups. The incidence of voice disorders in
school-age children was reported as 2–23%.2,3 Varying data
of the prevalence of childhood dysphonia are found in the
literature, ranging from 0.12% to 24% (Table 2).3–7,9,10 Voice
problems persist for 4 years or longer after identification in
38% of children with a voice disorder.4
There is a lack of studies into pediatric voice therapy12–16 and
the evaluation of voice therapy in children fits into this growing
interest.8–13 In this article, the effect of voice therapy on school-
age children is presented and it addresses the management of dys-
phonia associated with laryngeal inflammation, reduced vocal
fold mobility, benign vocal fold lesions, and functional voice dis-
orders. Pharmacologic or surgical treatments are not included.
Voice therapy in school-age children
In the field of voice therapy for children, the quality and the val-
idity of external evidence varies considerably. Limited evidence
Accepted for publication June 11, 2013.
From the Department of Ear, Nose and Throat, Speech and Voice Therapy Center, Bas-
kent University, Adana, Akdeniz, Turkey.
€ ul Akin Şenkal, Department of Ear,
Address correspondence and reprint requests to Ozg€
Nose and Throat, Speech and Voice Therapy Center, Baskent University, Adana, Akdeniz,
Turkey. E-mail: 444ozg@gmail.com
Journal of Voice, Vol. 27, No. 6, pp. 787.e19-787.e25
0892-1997/$36.00
Ó 2013 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2013.06.007
exists concerning the effectiveness of voice therapy alone, sur-
gery alone, no management, or a combination of surgery and
voice therapy. There is debate among professionals whether
to treat or not to treat these school-age children suffering
from hoarseness.3,8,12 Powell et al4 indicated that voice disor-
ders in school-age children persisted if they were not treated
well. Only 59% of ear, nose, and throat specialists prefer voice
therapy over surgery,8 and Deal et al17 indicated that vocal nod-
ules were reduced with voice therapy. The available evidence
for voice management options and specific voice therapy ap-
proaches are delineated in Table 3.
The voice therapy approaches are often divided into three
main categories: hygienic (improving behaviors that can lead
to injury of the vocal folds), symptomatic (targeting treatment
of abnormal voice quality in the resulting phonated voice),
and physiological (optimizing voice production).22
Thomas and Stemple22 conducted a systematic review of the
efficacy of voice therapy that revealed it was the best support
for physiological approaches and there were less strong data
for symptomatic approaches. To date, there has not been
a large-scale investigation of the efficacy of any given therapy
program for school-age children.23 This study aimed to eluci-
date the voice characteristics and the outcome of voice therapy
in school-age children with hoarseness with retrospective co-
hort data in Turkey.
METHODS
Subjects
Ninety-nine children (62 males and 37 females), of 7–15 years
of age (mean 10.56 [2.55]), were included in this study. They all
came to Baskent University Medical Center, Department of Ear
787.e20 Journal of Voice, Vol. 27, No. 6, 2013

tion was normal although they had existing hoarseness

TABLE 1.
Causes of Pediatric Voice Disorders3
(Table 5).
Acquired
Perceptual evaluation
Stress to the larynx (vocal abuse, misuse)
Two of speech-language pathologists (SLP) worked in this
Hyperfunctional (overuse) (too much, too long, too
loud speak) study at two different cities (Adana and Ankara) that assess
Coughing and loud forceful sneezing and diagnose school-age children with voice disorders. Percep-
Crying, laughing, shouting, cheering, and screaming tual analyses were performed by these trained SLP.
Throat clearing due to reflux or chronic upper On the same day of their clinic visit, SLP conducted an inten-
respiratory infections sive voice history survey and completed a voice use form with
Dryness due to medications (chronic asthma/allergies) the children’s parents. The purpose of the survey was to deter-
or restricted fluid intake mine the vocal habits of the children in the study.
Congenital For the subjective assessment of each subject’s quality of
Vocal fold paralyses voice, Grade, Roughness, Breathiness, Asthenia, and Strain
Laryngeal stenosis
(GRBAS), an assessment was performed by same SLP. Voice
Laryngomalacia
analysis records and conversations based on five parameters of
Webbing
Anterior laryngeal web the GRBAS system: grade ¼ overall degree of voice deviance;
roughness ¼ irregular fluctuation of the fundamental frequency;
breathiness ¼ turbulent noise produced by air leakage; asthenia ¼
Nose and Throat with a complaint of hoarseness between Jan- overall weakness of the voice; and strain ¼ impression of tense-
uary 2011 and December 2012. A comprehensive medical his- ness or excess effort. Each parameter was rated on a scale of 0–3
tory was obtained from each subject. None of them had received (0 was considered ‘‘normal’’; 1 ‘‘with slight disturbance’’; 2 ‘‘with
previous voice therapy or medication for their voice problems. moderate disturbance’’; and 3 ‘‘with severe disturbance’’).
The duration of the symptoms ranged from 2 months to 1 year. Children were asked to sustain an ‘‘aaa’’ sound for a comfort-
able period of time by using their common everyday pitch and
Stroboscopic evaluation loudness levels after the clinician’s sample. This was done three
Initially, all children were evaluated by an Ear, Nose, and times to obtain the maximum phonation time (MPT) measure.
Throat specialist. A stroboscopic evaluation of the larynx was Then, the mean score was calculated for the MPT score. The
successful in all children. The videolaryngostroboscopic exam- same procedure was completed for the s/z ratio measures for
ination of the subjects was performed by an Ear Nose and each child. The therapy was planned for the following session.
Throat Specialist. They were asked to sustain /i/ or /e/ phona-
tion during the examination. The endoscopic evaluation helps Voice therapy
to assess the upper airway, the laryngeal function and structure, Voice therapy was provided by same SLP once or twice per
and the velopharyngeal function.23 week and for 30 minutes in each session. The type of the ther-
These school-age children had the following seven existing apy and the frequency of the sessions were planned according to
pathologies: 62 of them had vocal nodules, nine had muscle the needs of each child. Total period of the therapy ranged from
tension dysphonia (MTD), two had vocal polyps, eight had mu- one to 11 sessions (mean 2.9).
tational falsetto, six had vocal fold edema, nine had laryngo- The voice therapy approaches are divided into three main
pharyngeal reflux (LPR), and one of them had vocal fold categories.16
paralysis. There were only two children whose larynx examina-
1. Hygienic voice therapy techniques: These therapy tech-
niques are designed to improve behaviors that can lead
TABLE 2. to injury of the vocal folds. Total period of the hygienic
Incidence and Prevalence Studies of Childhood therapy ranged from one to four sessions (mean 1.3
Dysphonia sessions).
Study Incidence Prevalence 2. Symptomatic voice therapy techniques: These therapy
Powell et al 4
— 203 child in 6–10 y techniques are designed to treat abnormal voice quality.
of age (n ¼ 847) Total period of the symptomatic therapy ranged from
Maddern et al3 6–23% — two to six sessions (mean 3.2 sessions).
Duff et al5 — 3.9% in 2–6 y of age 3. Physiological voice therapy techniques: These therapy
(n ¼ 2445) techniques are designed to optimize voice production.
Kiliç et al7 — 30.4% in school-age Total period of the physiological therapy ranged from
children (n ¼ 617) four to 11 sessions (mean 4.6 sessions).
Carding et al6 — 6% at 8 y of age (n ¼ 7389)
Boone et al9 7% Thus, 32 children were administered hygienic based, 27 of
McKinnon et al 0.12% in 36 primary
them physiological based, and 40 of them with symptomatic-
(2007)10 schools (n ¼ 1025)
based voice therapy. There were only nine children who also
€ u
Ozg € l Akin Şenkal and Mu
€ zeyyen Çiyiltepe Efficacy of Voice Therapy in School-Age Children 787.e21

TABLE 3.
Available External Evidence for the Management of Voice Problems in Children
Management Options Available External Evidence
Unspecified voice therapy Deal et al17,* Kay20,y Ramig and Verdolini18,z Trani et al21,y
Indirect voice therapy alone Mori19,k
Direct voice therapy Cook et al25,y Lee and Son16,{ Tezcaner et al11,{
* Randomized controlled study.
y
Nonexperimental study.
z
Systematic review.
k
Controlled studies without randomization.
{
Case series study.

required pharmacologic management in addition to their voice
therapy sessions, due to their being diagnosed with LPR (ie,
Proton Pomp Inhibitor). There were no other systemic patholo-
gies found in the children in the study. The family attended ther-
apy sessions to support the child’s attempts to modify behavior
and monitor exercising the vocal task at home.
Statistical analysis
The subjective voice assessments were carried out before and
after the completion of the therapy and the results were ana-
lyzed statistically. The results were given as arithmetic mean
(standard deviation). Subjective voice assessment data of pa-
tients before and after voice therapy were compared using Stu-
dent paired t test. Determination of statistically significant
differences in subjective parameters before and after voice ther-
apy was achieved with Wilcoxon signed-rank test. The differ-
ences were considered statistically significant for P < 0.001.
The data were analyzed using a MedCalc 9.2.0.1 program (Ó
1993–2013 MedCalc Software bvba, Acacialaan 22, B-8400
Ostend, Belgium).
RESULTS
There were 99 subjects in this study. Of the children included in
this study, 62 were male and 37 were female. The frequencies
according to sex and age groups are shown in Table 4.
The vocal nodules were the main cause of the school-age
children’s voice problems, accounting for 62.6% of the cases.
Of these children, 29% received physiological voice therapy,
40% symptomatic-based voice therapies, and 31% hygienic
voice therapies; 49% of children with LPR received physiolog-
ical management and 51% hygienic voice therapies. The chil-
dren with MTD were in another group. This group had all
three types of therapy, of which 55.5% had physiological man-
agement, 33.3% symptomatic management, and 11.2% hy-
TABLE 4.
Frequencies According to Sex and Age Groups
Age Group N (%) Mean Age (y)
Female 37 (37.3) 10.5
Male 62 (62.7) 11
Total 99 (100) 10.56
gienic voice therapy. For edema of the folds, 83.3% required
hygienic management and 16.7% symptomatic voice therapy.
The rest of the children, who were diagnosed with mutational
falsetto, vocal polyp, and vocal paralysis, were only treated
with symptomatic voice therapy. Children who had hoarseness
although they had a physiologically normal larynx received hy-
gienic voice therapy. The distributions of these findings are
shown in Table 5.
The GRBAS scale was also used before and after therapy ses-
sions for subjective voice evaluation. All the subjects demon-
strated varying degrees of hoarseness (G1–G3) and strained
(S1–S3) voices. Varying degrees of roughness (R1–R3) and
breathiness (B1–B3) were also noted. The GRBAS values be-
fore and after voice therapy are shown in Tables 6–8. In
general, changes in the value of the grade (measure of overall
degree of voice deviance) were statistically significant
(P < 0.0001) before and after therapy. Voice therapy was
effective for all the subjects and resulted in an improvement
of the GRBAS, especially grade scales.
Changes in the value of roughness (measuring irregular fluc-
tuation of the fundamental frequency) were statistically signif-
icant (P < 0.0001) for all type of voice therapies.
Changes in the value of breathiness (measuring turbulent
noise produced by air leakage) were statistically significant
(P < 0.0001) for hygienic and symptomatic voice therapies.
There were no significant changes for physiological voice ther-
apy (P ¼ 0.0001).
There were no significant changes in the values of asthenia
(measuring overall weakness of the voice) for all type of voice
therapies.
Changes in the GRBAS scale values with physiological and
symptomatic voice management were statistically significant
for strain (measuring impression of tenseness or excess effort)
(P < 0.0001). Strained quality of voice improved after physio-
logical and symptomatic voice therapy techniques.
In our study, one of the GRBAS parameters was not included
in the statistical analyses because the value of asthenia (A) pa-
rameter was 0 not only before the treatment but also after the
treatment.
Changes in MPT were statistically significant for all types of
voice therapy (Table 9) (P < 0.0001).
There were significant changes observed in the s/z ratio when
the values were compared before and after therapy sessions
787.e22 Journal of Voice, Vol. 27, No. 6, 2013

TABLE 5.
The Distribution of Voice Pathologies and Therapy Modalities
Physiological Voice Symptomatic Voice Hygienic Voice
Vocal Pathologies No of Children (%) Therapy (%) Therapy (%) Therapy (%)
Vocal nodules 62.6 29 40 31
MTD 9.09 55.5 33.3 11.2
Vocal polyps 2.02 — 100 —
Mutational falsetto 8.08 — 100 —
Edema 6.06 — 16.7 83.3
LPR 9.09 49 — 51
Vocal paralysis 1.01 — 100 —
Normal larynx 2.02 — 100
Total 100 27.7 40.4 32.32
Abbreviations: LPR, laryngopharyngeal reflux; MTD, muscle tension dysphonia.

(Table 10). These changes were seen in all three types of voice
therapy techniques. With the physiological therapy, the s/z ratio
increased from 0.72 to 0.84. The ratio increased from 0.86 to
0.91 with the hygienic voice therapy and 0.84 to 1 with the
symptomatic voice therapy. When the differences in the statis-
tical measures were examined according to the voice therapy
techniques, the changes in the s/z ratio were only statistically
significant with the symptomatic voice therapy (P < 0.0001).
DISCUSSION
Voice disorders can impact on a child’s oral communication and
limit their participation in classroom activities because of unin-
telligibility or embarrassment.15–17 Strategies for treating
children with voice disorders have historically been derived
directly from therapeutic strategies used for adults with voice
disorders. The most suitable voice therapy for school-age
children is still under debate.8,11,12,16,17,19,24,25 Therapeutic
success is often the result of a combination of different
treatments.11,17,19 However, there are still questions as to the
effectiveness of voice therapies alone. Recent literature has
shown an increased interest in treatment outcomes.10–13 Many
of the studies report voice evaluations on children before and
after therapy.11,16
Tezcaner et al analyzed the efficiency of the voice therapy in
39 patients with vocal fold nodules, aged between 7 and
14 years on a prospective study. The authors reported a signifi-
cant improvement in the acoustic analysis parameters of jitter,
shimmer, and noise-to-harmonic ratio.11 Lee and Son reported
on a retrospective review of the clinical records of eight Korean
male children diagnosed as having MTD, seven of whom had
bilateral vocal nodules on laryngoscopic examination. The au-
thors reported that a few sessions of voice therapy, focusing on
awareness, relaxation, respiration, and easy-onset phonation
to reduce the tension around the laryngeal muscles, resulted
in dramatic improvement of their voice quality and pitch
adjustment.16
In a systematic evidence review of voice therapy, Speyer
reported that due to the small number of published treatment
outcome studies and the methodological heterogeneity among
published studies, very few conclusions relative to the effective-
ness of voice therapy ‘‘in general’’ may be drawn from the lit-
erature. From the results of his review, Speyer suggests
a tendency for positive intervention outcomes to be more com-
monly reported for (a) very specific therapy approaches such as
manual laryngeal tension reduction or the Accent method of
voice therapy and (b) for studies focusing on specific clinical
populations such as mutational falsetto or vocal nodules.2

TABLE 6.
GRBAS Data (Mean, Standard Deviation, and P Values Before and After Voice Therapies are Shown) Before and After
Physiological Voice Therapy
Before Physiological After Physiological
n ¼ 27 Voice Therapy Voice Therapy P Values
Grade 2 (1) 0.6 (0.49) <0.0001
Roughness 1.7 (0.5) 0.81 (0.07) <0.0001
Breathiness 1.11 (0.75) 0.44 (0.5) ¼0.0001
Asthenicity 0 0
Strained 0.88 (0.32) 0.4 (0.5) <0.0001
P values on Wilcoxon signed-rank test, mean ± standard deviation of pretherapy and posttherapy measures are reported for all patients. Statistically significant
P values were indicated in bold characters.
€ u
Ozg € l Akin Şenkal and Mu
€ zeyyen Çiyiltepe Efficacy of Voice Therapy in School-Age Children 787.e23

TABLE 7.
GRBAS Data (Mean, Standard Deviation, and P Values Before and After Voice Therapies are Shown) Before and After
Hygienic Voice Therapy
Before Hygienic After Hygienic
n ¼ 32 Voice Therapy Voice Therapy P Values
Grade 1.31 (0.6) 0.71 (0.45) <0.0001
Roughness 1.7 (0.72) 0.56 (0.5) <0.0001
Breathiness 0.9 (0.68) 0.28 (0.45) <0.0001
Asthenicity 0 0
Strained 0.78 (0.6) 0.31 (0.4) ¼0.0001
P values on Wilcoxon signed-rank test, mean ± standard deviation of pretherapy and posttherapy measures are reported for all patients. Statistically significant
P values were indicated in bold characters.

Clinicians reported that treatment is important in preventing fu-
ture problems in adolescence and adulthood, but data are not
available to show whether treatment is successful for chil-
dren,24 especially focusing on school-age children. This study
aimed to determine effective voice therapy techniques for
school-age children with hoarseness. In this study, based on in-
ternational literature, subjective parameters were considered:
the s/z ratio, MPT, and the GRBAS scale. All the parameters
taken into account in this study were subjective voice assess-
ments. There is no standardized value for objective voice eval-
uations for children today in Turkey. Limitations of this study
include retrospective nature and lack of control group. How-
ever, this study included a large sample focusing on a specific
clinical population.
In this study, the most common voice problems in the school-
age children were vocal nodules (62.6%). Kiliç et al7 found that
2.8% of school-age children had mature nodules. Tezcaner
et al11 stated that in school-age children, the estimated inci-
dence of vocal fold nodules is approximately 17–30% and is
more common in boys. In spite of the high prevalence of vocal
fold nodules, there is no standardization in the choice of ther-
apy technique in the management of vocal fold nodules in
children.
In particular, the results of this study showed that physiolog-
ical voice therapies are effective for treating roughness and
strained voice quality. Physiological voice therapy is an ap-
proach to balancing the three subsystems of voice production
at once. This kind of systematic voice exercises strengthen
and rebalance the subsystems involved in voice production (res-
piration, phonation, and resonance). Exercises include maxi-
mum vowel prolongations and pitch glides using specific
pitch and phonetic contexts. Thus, physiological voice therapy
techniques for school-age children eliminated roughness and
strained voice quality in this study. Physiological voice therapy
techniques are structured as behaviorally based voice therapy
protocols and had a positive effect on voice quality, vocal status,
and vocal function of the school-age children. Hence, physio-
logical voice therapy techniques cannot always be suitable for
school-age children. Physiological voice therapy techniques re-
quire the active participation and long-term applications of chil-
dren, their parents, and the voice therapist.
Tezcaner et al11 showed that eclectic therapy techniques have
positive effects on children with vocal nodule problems and
stated that eclectic voice therapy techniques require more
follow-up and cooperation with the child. School-age children
and their parents cannot always allocate long-term time to phys-
iological voice therapy sessions, depending on daily living con-
ditions. Furthermore, therapy sessions are not always suitable
for school-age children. On the other hand, hygienic or symp-
tomatic voice therapy methods are also preferable for the voice
therapist when dealing with an uncooperative child. The phys-
iological voice therapy techniques that were followed by symp-
tomatic voice therapy were also found to be valid for school-age
children in this study.

TABLE 8.
GRBAS Data (Mean, Standard Deviation, and P Values Before and After Voice Therapies are Shown) Before and After
Symptomatic Voice Therapy
Before Symptomatic After Symptomatic
n ¼ 40 Voice Therapy Voice Therapy P Values
Grade 1.42 (0.87) 0.65 (0.57) <0.0001
Roughness 1.3 (0.51) 0.57 (0.5) <0.0001
Breathiness 1.3 (0.75) 0.27 (0.45) <0.0001
Asthenicity 0 0
Strained 1.258 (0.63) 0.52 (0.55) <0.0001
P values on Wilcoxon signed-rank test, mean ± standard deviation of pretherapy and posttherapy measures are reported for all patients. Statistically significant
P values were indicated in bold characters.
787.e24
TABLE 9.
Voice Management Techniques and MPT Data (Mean,
Standard Deviation, and P Values Before and After Voice
Therapies are Shown)
MPT (s) MPT (s)
Voice Therapy Before Tx After Tx
Physiological 6.18 (2.11) 11.9 (2.5)
Hygienic 6.8 (2.2) 11.87 (2.5)
Symptomatic 6.97 (2.8) 12.57 (3.22)
P values on Wilcoxon signed-rank test, mean ± standard deviation of pre-
therapy and posttherapy measures are reported for all patients. Statisti-
cally significant P values were indicated in bold characters.
Symptomatic voice therapy is an approach that works di-
rectly on single voice components, such as pitch, loudness, res-
onance, or respiration.22 In this study, symptomatic voice
therapy techniques were used to improve voice production
through better vocal folds approximation and to reduce laryn-
geal area muscle tension and effort (vocal hyperfunction),
such as the Chewing exercise, Yawn-sigh technique, EMG bio-
feedback, and Manual Circumlaryngeal Therapy (Digital Mas-
sage). The symptomatic voice therapy was found to be the most
successful method of therapy for school-age children in this
study. Changes in GRBAS, MPT, and s/z ratio were statistically
significant for symptomatic voice therapy. Recent literature
concluded that symptomatic voice therapy methods are the
most frequently recommended type of treatment for vocal nod-
ules and are highly individualized based on the severity of
symptoms, suspected causes, duration of the nodules, and vocal
demands of the client.22 Symptomatic voice therapy techniques
are not required for more than several weeks and not compli-
cated to understand and their instructions are not hard to follow.
Hygienic voice therapy techniques, therefore, focus on the
identification and subsequent elimination of poor vocal behav-
iors, followed by the development of proper vocal behaviors.
Within this framework, vocal hygiene management has been
characterized in a number of ways.22 A study of 38 elementary
grade school-age children with hoarse voices who participated
in a six-lesson, cartoon-illustrated vocal hygiene program indi-
cated that the children learned the vocal hygiene concepts pre-
sented.25 Hygienic methods could be used to eliminate or
modify behavioral voice problems. In this study, there was an
TABLE 10.
Voice Management Techniques and s/z Ratio Data (Mean
and P Values Before and After Voice Therapies are
Shown)
s/z (s) Before s/z (s) After
Voice Therapy Tx Tx
Physiological 0.72 0.84
Hygienic 0.86 0.91
Symptomatic 0.84 1 <0.0001
P values on t test, mean of pretherapy and posttherapy measures are re-
ported for all patients. Statistically significant P values were indicated in
bold characters.
Journal of Voice, Vol. 27, No. 6, 2013
improvement in roughness and breathy voice quality by using
hygienic voice therapies in school-age children.
Merati et al (2008) showed that pediatric patients with vocal
fold paralysis, vocal nodules, and paradoxical vocal fold dys-
function face significant impairment as compared with control
populations. Children in the study by Merati et al26 demon-
P
strated a statistically significant impairment in age-matched
<0.0001 children for total Pediatric Voice Related Quality of Life Ques-
<0.0001 tionnaire (PVRQOL), as well as for the Social-Emotional and
<0.0001 Physical-Functional domains. Taking this information into ac-
count, the need for voice therapy in solving voice problems in
children is a very important issue. Future studies need to be rep-
licable and to generalize to inform and elucidate clinical
practice.
CONCLUSION
Voice therapy in school-age children is one of the most difficult
areas for therapy. Traditional voice treatment typically focuses
on vocal hygiene, worksheets, and reducing ‘‘abusive’’ voice
behaviors, such as yelling. These approaches, however, have
limited effectiveness.
There are multiple variables related to voice therapy tech-
niques for school-age children, which affect the effectiveness
of the therapy. These range from the clinician’s experience to
the parents’ involvement and more specifically to the child ac-
tively applying the techniques presented in each session and us-
ing them in his or her day-to-day life. Data from the present
study suggest that the symptomatic voice therapy may be help-
ful in treating hoarseness in school-age children in an outpatient
clinical setting. In our experience, the active collaboration of
parents is fundamental for achieving objectives. Additionally,
the scholastic environment is very important. So, a voice ther-
apist should place importance on the vocal behavior of teachers
who are the first vocal model for children outside of the home. It
would be worthwhile organizing meetings with all primary
school teachers to help them understand communicative capa-
bilities at different ages and to prevent voice problems.
This retrospective study has the disadvantage that it does not
follow school-age children whose hoarseness continues after
the voice therapy. However, this study proved, based on
a very large sample, the effectiveness of hoarseness manage-
ment in school-age children in outpatient clinics in university
hospitals in two different cities in Turkey (Adana and Ankara).
Finally, although many studies reviewed in the literature for
voice therapy are stronger, much more has been added by this
study with regards to the evidence for the efficacy of treating
hoarseness in school-age children.
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3. Maddern BR, Campbell TF, Stool S. Pediatric voice disorders. Otolaryngol
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4. Powell M, Filter MD, Williams B. A longitudinal study of the prevalence of
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€ u
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