Portuguese Version

Year:  2001  Vol. 67   Ed. 6 - (7º)

Artigo Original

Pages: 804 to 807

PDF PT  

Childhood's disphonia epidemiologic aspects

Author(s): Erich Christiano Madruga de Melo 1,
Fernando Marcos Mattioli 1,
Osiris C O Brasil 2,
Mara Behlau 3,
Ana C A Pitaluga 4,
Danielly Madruga de Melo 5

Keywords: dysphonia, children, larynx

Abstract:
Introduction: In the latest years the diagnosis of voice disorders in children have been facilitated by the development of easy application diagnostic methods, such as videolaringoscopy. Aim: The aim of this study is to assess the prevalence of the various laryngeal lesions through videolaringoscopy in children with voice complaints seen at "Setor de Laringologia do Serviço de Otorrinolaringologia do Hospital do Servidor Público Estadual de São Paulo". Study design: Retrospective clinical no randomized. Material and method: From March 1999 to March 2000 we analyzed 34 children. At this study, the main interest was in the sex incidence, type of laryngeal lesion, if isolated or associated; glottic closure and presence of suggestive signals of GER. Results: We found 18 children with vocal fold nodules (53%), 7 with vocal fold cyst (21%), 1 with nodular lesion (3%) and 8 with normal evaluation (23%). The children with vocal fold nodules aged 4 to 13 years, mean 9 y-old; no sex correlation. The children with vocal fold cyst aged 10 to 13 years, with an average of 11,2 years old; no sex correlation. Findings of GERD were suggestive in only one child, with diagnose of vocal fold nodules. Conclusion: The most frequent lesion in children with disphonia was vocal fold nodule, without sex correlation, mean 9 y-old.

Introduction

Parents and educators are not very concerned about vocal abnormalities in children, which leads to controversial incidence of dysphonia in childhood population, as reported in the literature.
Epidemiological studies conducted in schools referred incidences of childhood dysphonia ranging from 6 to 23.4%, depending on the location of the school, varied aspects and a series of methodological considerations2. Among the different studies, we may refer to the ones by Pont (1965), who found an incidence of 9.1%; Baynes (1966), 7%; Senturia & Wilson (1968), 6%; Silverman & Zimmer (1974), with the highest incidence, 23.4%; Yari et al. (1974), 13% of acute hoarseness and 5% of chronic hoarseness, and Warr-Leeper et al. (1979), 7% of childhood dysphonia.

Etiology of childhood dysphonia may vary from self-limiting affections, such as acute viral laryngitis, to disabling and life-threatening conditions, such as laryngeal tumors and stenosis of different degrees9.

However, the common clinical observation, practically universal, is that in average, 70% of the hoarse children have vocal nodules. The peak of incidence is between 5 and 10 years of age, no gender difference, although there is a trend towards male patients, probably because of social requirements of aggressiveness in males. Causal factors of dysphonia may be grouped as follows: inappropriate life style, environmental, physical and psychological factors, personality structure, phonation non-adaptation and allergic factors, among others.

Diagnosis of dysphonia in children has been made easier by the development of easy to perform diagnostic methods, such as videolaryngoscopy 9.

The present study aimed at assessing the incidence of different laryngeal affections in videolaryngoscopic examinations of children with vocal complaints, followed up by the Division of Laryngology, Service of Otorhinolaryngology, Hospital do Servidor Público Estadual de São Paulo, between March 1999 and March 2000. We focused on data concerning incidence according to age, gender, type of laryngeal lesion, isolated or combined lesion, glottic closure and presence of suggestive signs of gastroesophageal reflux.

Table 1.

Results

We reevaluated 34 examinations of 18 boys (53%) and 16 girls (47%), ages ranging from 4 to 13 years, mean age of 9.47 years. Eighteen children were identified as having vocal nodule, 7 had vocal fold cyst; 1 had the diagnosis of non-specific nodular lesion and in 8 children the examination was normal. Findings are shown in Table 1.

Out of 18 children with vocal nodule, 9 (50%) were male and 9 (50%) were female patients, ages ranging from 4 to 13 years, mean age of 9 years. In 17 (94%) children, the nodule was an isolated lesion, and in 1 (6%) child it was associated to anterior laryngeal microweb. As to glottic closure, 12 (67%) children presented glottic chink divided into 7 (39%) middle-posterior triangular chinks; 3 (17%) double ones and 2 (11%) posterior triangular chinks. We found suggestive signs of gastroesophageal reflux in only 1 (6%) child who had the diagnosis of vocal nodule.

Among the 7 children with diagnosis of vocal fold cyst, 4 (57%) were boys and 3 (43%) were girls, aged 10 to 13 years, mean age of 11.2 years. In 6 (86%) cases, the cyst was an isolated lesion, whereas in only 1 (14%) case the lesion was associated with vasculodysgenesia in the same vocal fold. As to glottic closure, 6 (86%) of the children had glottic chink: 5 (71%) irregular chinks and 1 (14%) hourglass chink. We did not find suggestive signs of gastroesophageal reflux in children with diagnosis of vocal fold cyst.

DISCUSSION

Affections that compromise children's larynxes, leading to dysphonia, may be didactically divided into causes that are infectious, inflammatory, tumor, vocal fold paralysis, congenital functional and organic-functional9.

Vocal nodule is considered a lesion that characterizes organic-functional dysphonia, and it is the main cause of vocal disorders in children and adolescents3, 4, 12.

Vocal nodules are characterized as exophitic, bilateral masses, symmetrical in localization but not in size, more or less flexible, localized in the transition of the middle to anterior thirds of the vocal folds, especially in the vibrating area, that is, the site that has more vocal fold vibration amplitude, where there is more mechanical surface contact. Vocal nodules are lesions of the epithelium of the vocal folds, in which there is duplication or triplication of the epithelial basal membrane.

The presence of vocal nodule determines a series of alterations in phonation dynamic physiology, such as aperiodical and irregular vibration of the vocal folds, owing to the imbalance between laryngeal myoelastics forces and pulmonary aerodynamic forces.

Children's larynxes generally present larger nodules and the vocal folds are not able to close completely during phonation, causing sounded air leak, which may lead to an attempt to compensate through increased muscle tension and vocal intensity.

A number of studies appointed to nodules as the lesion responsible for 38 to 78% of the chronic dysphonias in children10. The peak of incidence, according to previous reports, are between 5 and 10 years of age, with no gender difference, although after the age of 15 years there is an almost total decrease of incidence in males; in adult life, the condition affects almost only women.

Vocal nodule was the lesion most frequently found in children with vocal complaint, present in 18 out of 34 children (53%). Age at diagnosis varied from 4 to 13 years, mean age of 9 years, and there was no gender difference.

In 12 children (67%), glottic closure was incomplete, with a middle-posterior triangular chink in 7 cases (39%), posterior triangular in 2 (11%) and double chink in 3 (17%) of the cases. Middle-posterior triangular chink is known as the typical chink in cases of nodule, probably because of hypertonicity of the posterior cricoarytenoid muscle during phonation, which is more common in women and children because of the laryngeal configuration of these individuals (Belhau & Pontes, 1995). Double chink normally represents a middle-posterior triangular chink with mucosal lesions associated to uni or bilateral localized edema that causes even larger opening, by mechanical rather than muscular issues.

As to genesis of nodules, in addition to genetic and constitutional formation factors, hyperactive and aggressive behavior, tendency to lead and excessive speech at loud levels used by children can be considered causal, predisposing or aggravating factors of childhood dysphonia, which should be considered a multifactorial condition.

Vocal cyst was the second most frequent lesion in our sample, present in 7 children (21%). Sarfati & Auday (1996) found an incidence of 29%, in 45 studied children; Danoy, Heuillet-Martin and Thomassin (1990) reported a 20% incidence of cysts.

Cysts are alterations of the vocal fold lining, considered embryogenic deviations and classified as minimal structural alterations by some authors3, 9. The age of children with vocal cyst in the present study varied from 10 to 13 years, mean age of 11.2 years, higher than that of children with nodules. We did not observe gender differences either.

The lesion was isolated in 6 children with cysts (86%) and only one case (14%) had associated vasculodysgenesia. As to glottic closure, in 6 cases (86%) we observed glottic chink and 5 of them (71%) had irregular types, not characterizing any muscle adaptation associated with the lesion.
Cysts are located on the lamina propria of the vocal fold, recovered by the stratified squamous epithelium, and normally adhered to elastic and collagen fibers of the vocal ligament. Vocal cysts can be mistaken by nodules, especially if bilateral, because of its similar macroscopic aspect and localization.

We found suggestive signs of gastroesophageal reflux in only one child with vocal complaint and with diagnosis of nodule; there were no cases with the diagnosis of cyst and gastroesophageal reflux. These findings do not agree with the recent literature data8, 11, such as the study by Contencin et al. (1999), in which the authors diagnosed the presence of gastroesophageal reflux, by 24-hour pH monitoring, in 59% of 17 children with chronic dysphonia. Contencin et al. (1997) also identified through pH monitoring the presence of gastroesophageal reflux in 64% of 20 children with chronic dysphonia.

Conclusion

The analysis of the results of the present study that evaluated 34 children with vocal complaint, aged 4 to 13 years, using laryngoscopy, led us to the following conclusions:
1. The most frequent lesion in children with dysphonia was vocal nodule, found in 18 out of 34 children (53%);
2. The age of children with vocal nodules ranged from 4 to 13 years, mean age of 9 years. There was no correlation with gender;
3. The second most common lesion was vocal cyst, present in 7 out of 34 children (21%);
4. The age of children with vocal cyst varied from 10 to 13 years, mean age of 11.2 years. There was no correlation with gender;
5. Findings suggestive of gastroesophageal reflux were found in only one case, a child with vocal nodule.

References

1. BAYNES, R.A. - An incidence study of chronic hoarseness among children. J Speech Dis., 31:172-5, 1966.
2. BEHLAU, M.S. & GONÇALVES, M.I.R. - Considerações sobre Disfonia Infantil. In: FERREIRA, L.P. Trabalhando a Voz - Vários Enfoques Fonoaudiológicos, Summers editorial.
3. BEHLAU, M.S. & PONTES, P.A. - Avaliação e Tratamento das Disfonias. São Paulo, ed. Lovise, 1995.
4. BLOOM, L.; ROOD, S. - Voice Disorders in Children: structure and evaluation. Pediatr. Clin. North Am., 28:957-63, 1981.
5. CONTENCIN, P.; GUMPERT, L.; KALACH, N. e col. - Laryngite Chonique chez Lénfant: Place du Refux Gastro-Oesophagien. Ann Otolaryngol Chir Cervicofac 116:2-6, 1999.
6. CONTENCIN, P.; GUMPERT, L.; KALACH, N. e col. - Reflux gastro-oesophagien et dysphonie chez lénfant. Rev Laryngol Otol Rhinol 118(4):253-7, 1997.
7. DANOY, M.C.; HEUILLET-MARTIN, G.; THOMASSIN, J.M. - Les dysphonies de lénfant. Revue de Laryngologie 111(4), 1990.
8. FEEHS, R. S.; KOUFMAN, J. A. - Laryngitis. In: BAYLEY, B. J. Head and Neck Surgery - Otolaryngology, vol. one, Philadelphia, Pennsylvania J B Lippincott Company, pp. 612-9, 1993.
9. FREITAS, M.R.; WECKX, L.L.M.; PONTES, P.A. - Disfonia na Infância. Revista Brasileira de Otorrinolaringologia, 66(3):257-64, 2000.
10. GRAY, S.D.; SMITH, M.E.; SCHNEIDER, H. - Voice disorders in children. Pediatric. Clin. North Am, 43(6):1357-84, 1996.
11. GUMPERT, L.; KALACH, N.; DUPONT, C.; CONTENCIN, P. - Hoarseness and gastroesophageal reflux in children. J. Laryngol. Otol.,112:49-54, 1998.
12. HIRSCHBERG, J.; DEJONCKERE, P.H.; HIRANO, M. et al. - Voice disorders in children. Int. J. Pediatr. Otorhinolryngol.,32:S109-25, 1995.
13. PONT, C. - Hoarseness in children. West Mich. Univ. J. Speech Ther., 2:6-8, 1965.
14. SARFATI, J.; AUDAY, T. - Evalution des dysphonies bénignes de lénfant. Rev. Laryngol. Otol.Rhinol, 117(4):327-9, 1996.
15. SENTURIA, B. H.; WILSON, F. B. - Otorhinolaryngologic findings in children with voice deviations. Ann. Otol., 77:1027-41, 1968.
16. SILVERMAN, E.M.; ZIMMER, C.H. - Incidence of chronic hoarseness among school-age children. J. Speech Dis., 40:211-5, 1975.
17. WARR-LEEPER, G.A.; McSHEA, R.S.; LEEPER, H.A. - The incidence of voice and speech deviations in a middle school population. Lang. Speech Hear. Ser. Schools, 10:14-20, 1979.
18. YARI, E.; CURRIN, L.; BULIAN, N.; YAIRI, J. - Incidence of hoarseness in school children over a one year period. J. Commun. Dis., 7:321-8, 1974.

---

1 Resident Physician, Service of Otorhinolaryngology, Hospital do Servidor Público Estadual de São Paulo/ Fmo
2 Physician, Head of the Division of Head and Neck Surgery, Service of Otorhinolaryngology, Hospital do Servidor Público Estadual de São Paulo / FMO; Ph.D. in Medicine, Escola Paulista de Medicina - Unifesp
3 Speech Therapist, Ph.D. in Sciences, Universidade Federal de São Paulo - EPM; Director of Centro de Estudos da Voz - CEV, São Paulo
4 Assistant Physician, Service of Otorhinolaryngology, Hospital do Servidor Público Estadual de São Paulo / FMO; Master in Otorhinolaryngology and Head and Neck Surgery, Escola Paulista de Medicina - Unifesp
5 Undergraduate, Speech and Hearing Therapy, Centro Universitário de João Pessoa

Study conducted at Hospital do Servidor Público Estadual de São Paulo - São Paulo - SP
Address correspondence to: Erich Christiano Madruga de Melo - R. Borges Lagoa, 1565 Apto 10 - Vl. Clementino - São Paulo - SP - 04038-034 -
Tel: (55 11) 5572-3764 - E-mail: erichmelo@uol.com.br
Article submitted on May 10, 2001. Article accepted on June 29, 2001.

Print: