Young girl speaking with mother


Voice Disorders

Our Center treats a variety of conditions that can affect your child's voice. If your child has symptoms consistent with any of the following conditions, call us at 617-573-3190 to schedule an appointment or request one online.

PVFM

Paradoxic vocal fold motion (PVFM), also known as vocal cord dysfunction, is abnormal movement of the vocal cords when breathing in.
 

Symptoms

This usually presents as a feeling of throat closing, chest tightness, or shortness of breath during exertion or any anxiety-provoking situation.

Diagnosis

On physical exam, a small, thin, flexible scope is passed through the nose and used to examine the voice box. We look for inward movement of the vocal cords while breathing in. 

This can be difficult to capture in the clinic, so the patient may be referred for an exercise test, in which exercise is performed to the point of intensity necessary to elicit symptoms, and then the flexible scope is passed to examine the voice box. 

The physician will also want to rule out other causes such as GERD, asthma, allergy, structural abnormalities, or cardiac issues.


Treatment

Treatment typically includes voice therapy with a speech and language pathologist, as well as biofeedback and behavior modification with a psychiatrist trained in these specific modalities.

Related Articles

Pediatric paradoxical vocal-fold motion: Presentation and natural history
Validation of the Dyspnea Index in adolescents with exercise-induced paradoxical vocal fold motion

Velopharyngeal Insufficiency

Velopharyngeal insufficiency (VPI) is an inability to effectively seal the nose from the mouth during speech. Children with VPI often speak in a very nasal tone, such that with certain sounds air will leak from the nose, making the words hard to understand. It occurs for a variety of reasons, from problems with the soft palate that children are born with to children who have had surgical repair of a cleft palate. Because of this wide range of causes, approaches to diagnosis and treatment may vary and often must be tailored to the individual child.

Diagnosis

VPI may initially present due to problems with understanding speech. Further diagnosis may be suspected after a clinical speech evaluation is performed by a speech-language pathologist. Formal diagnosis is usually obtained by nasometry (a computer-based measuring tool that examines the amount of airflow at the nose during speaking) and videofluoroscopy (special x-ray performed during speech). In some cases, a small, thin, flexible scope is passed through the nose and used to examine the back of the nose and palate during speaking.

Treatment

In general, some children have problems with anatomy that may require surgery first. While other children have problems with function that may benefit from a special form of voice therapy. Overall, most children will have some form of special speech therapy for this condition, even if it occurs after surgery.

Current Ongoing Clinical Research

We are actively recruiting children with VPI, 22Q anomalies, and midline carotid arteries to characterize the success of a new surgical technique. We are also recruiting children with VPI to assess the role of real-time MRI imaging to help us best choose between the various surgical options and achieve better vocal outcomes. For more information, please email christopher_hartnick@meei.harvard.edu.


Related Articles

Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency
Stress velopharyngeal incompetence: Two case reports and options for diagnosis and management
Furlow double-opposing z-plasty

Vocal Fold Immobility

In children with vocal fold immobility (VFI) either one or both vocal folds are not moving properly.

Symptoms

Symptoms of vocal fold immobility can include hoarseness, breathing issues, and/or problems with swallowing. With swallowing, liquids or solids may head toward or into the airway (penetration/aspiration) causing further breathing problems.

Diagnosis

Vocal fold immobility can occur for a variety of reasons. Your child's history is very important is helping with diagnosis. 

  • Was your child born with this condition? 
  • Was it the result of a surgery during which the nerve that controls the vocal fold was injured? 
  • Is there a mass or growth pressing on the nerve? 
  • Is the nerve working, but the joint that allows the vocal fold to move may be stuck (perhaps due to local trauma or a prior use of a breathing tube)? 
To answer these questions, the physician may need to perform an endoscopy, a procedure in which a small scope is passed into the airway while the patient is asleep. In other cases, an imaging study of the child’s head, neck, and chest (such as an MRI) is done. Finally, a special study that tests the muscle function of the vocal cord may be considered, which is also done while the patient is asleep, usually at the same time as the endoscopy.

Treatment

Because of this wide range of causes, approaches to treatment may also vary. Some cases of VFI will resolve over time, but management of the symptoms is necessary while waiting for recovery. 

Those with one vocal cord not moving may have voice or swallowing problems. If these symptoms are severe, a short-term solution would include a temporary surgical procedure with injection of a slowly dissolving material that moves the vocal cord into a better position. If the movement does not recover, certain surgeries can provide a more long-term option such as thyroplasty or nerve reinnervation (see nerve reinnervation surgical video here)

Those with both vocal cords not moving often have significant trouble breathing and may require a tracheostomy for a short time. If neither vocal fold regains function, then these children are candidates for procedures to help open the airway (vocal cordotomy, arytenoid lateralization, and airway reconstruction) and work toward removing the tracheostomy if it is present.

Current Ongoing Clinical Research

We are actively recruiting children with VFI to identify the ideal age for nerve reinervation. For more information, please email christopher_hartnick@meei.harvard.edu.

Other

Voice disorders place more than five million school-aged children at increased risk for inferior school performance and poor social development.

Causes

The most common cause of pediatric vocal dysfunction is the presence of vocal fold nodules, but there are a variety of other causes such as vocal cysts or polyps, respiratory papilloma, vocal fold immobility, and other lesions of the vocal folds.

Diagnosis and Treatment

It is important for the surgeon to actually visualize and assess any lesions on the child’s vocal cords through endoscopic evaluation before beginning voice therapy treatment.

Current Ongoing Clinical Research

We are actively recruiting children with laryngeal vocal nodules 1) to perform optical coherence technology (OCT) analysis to assess whether lesions are nodules that need voice therapy or other lesions that might not; and 2) to obtain voice samples to build a voicebank to help inform whether or not a laryngoscopy is necessary in children. For more information, please email christopher_hartnick@meei.harvard.edu.


Related Articles

Voice therapy for children with vocal nodules: A randomized clinical trial
Management of unilateral true vocal cord paralysis in children
Surgery for pediatric vocal cord paralysis: A retrospective review
Surgery for pediatric vocal cord paralysis: A meta-analysis
Vocal fold medialization in children
Establishment of a normative pediatric acoustic database
Consistency of voice frequency and perturbation measures in children using cepstral analyses: A movement toward increased recording stability
Establishment of a normative cepstral pediatric acoustic database 
Pediatric Laryngeal Diadochokinetic rates: Establishing a normative database
Evaluation of true vocal fold growth as a function of age
Consistency of voice frequency and perturbation measures in children
Development and maturation of the pediatric human vocal fold lamina propria