User:Adriana gentile/sandbox

.Things I plan to add to the article "Voice Therapy"

- Improve overview section based on general information on voice disorders, common Tx procedures and applications. Info for this can be found on ASHA : http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942600&section=Treatment#Treatment_Approaches

- Improve Applications section: add "Voice Therapy in Children' section.

Voice Therapy in Children

In children, the presence of voice disorders and dysphonia is quite common, although the reported prevalence varies significantly depending on the type of data collection and the location from which it was drawn. Some estimates suggest a rate between 6 and 38% of school-aged children, others indicate between 2 and 23%. Dysphonia is more common in male children than females during school-age. Conversely, as of 13 years and through to adulthood the disorder is more commonly seen in females. Other voice disorders such as vocal nodules, are also common in children, particularly before the onset of puberty with an incidence of 17-30%. The most common vocal pathologies occuring in children are nodules (55-68% of cases) and damage caused by congenital lesions (27-41% of cases). Other common pathologies in children include vocal fold cysts and polyps. The presence of dysphonia in children can impact psychological well-being and social functioning both in academic and family life and can significantly influence a child's ability to perform daily functions.Moreover, pediatric voice disorders may progress into adulthood and consequently affect personal and professional ambitions negatively. As a result of these consequences, the United States have implemented a federal mandate through the Individuals with Disabilities Act which states that children with voice disorders that impact their academic performance are entitled to in-school services. Despite this, the criteria for school based services is up to interpretation, and children with voice disorders receive inconsistent access to treatment.

Epidemiology

There are various different types of dysphonia with distinct epidemiologies.

1. Acute dysphonia usually triggered by an infectious onset.
   • Juvenile Recurrent Respiratory Papillomatosis (RRP), subglottic stenosis
2. Endocrine pathology induced VT
3. Laryngeal conditions that lead to chronic childhood voice disorders.
   • vocal fold nodules/ cysts, velopharyngeal insufficiency (VPI), anterior glottic webs, vocal fold paralysis
4. Functional voice disorders (ie. no neurologic/ anatomical etiology)
   • muscle tension dysphonia, puberphonia/mutational falsetto

Pediatric Voice Therapy

Pediatric voice therapy involves the collaborative work of often multidisciplinary healthcare practitioners forming the voice-care teams. In pediatric cases, the Speech Language Pathologist (S-LP) is usually the primary treatment provider. His or her work may be facilitated by other team members depending on the issues involved. These include a pediatric otolaryngologist, pulmonologist/allergist and nurses. Additionally, other members of the voice-care team can include general practitioners, surgeons, social workers, occupational therapists, dieticians, gastroenterologists and pharmacists. Voice services can be provided in a number of settings, including hospitals, clinics, schools and personal homes.

Assessment

1. Interview: The first step of assessment in childhood dysphonia is the interview. In the interview, the clinician must learn who first noticed the dysphonia, the age of onset (early years/months suggests congenital pathology, school age (3-4 years) suggests acquired pathology), as well as the evolution of the disorder. Variation in the presentation of the disorder can be very helpful in guiding the voice therapy. For example, if the voice improved on weekends, this could suggest an underlying problem with vocal behaviour. Similarly, if the voice pathology remained stable or varied significantly regardless of context, it is likely unrelated to vocal effort and suggestive of a congenital malformation of the vocal structure. The interview process also includes the collection of a thorough history which informs the clinician of potential risk factors affecting the child (i.e. prematurity, NICU stay, family history, ENT surgeries, hearing impairment etc). In these instances the clinician should screen for swallowing, pneumologic and digestive impairments which could be contributing to the dysphonia. Other important factors to take note of during the interview include the child's personality (ie. introverted/extroverted, carefree/anxious), how they communicate as well as what their home and school environment is like. All of these factors may contribute to the voice disorder itself, as well as to its impact on the child's social fuctioning.
2. Voice Function Assessment: A clinical assessment of voice function includes a laryngeal exam, perceptual examination of vocal characteristics, the collection of voice samples (reading, singing, loud voice, prolonged vowels etc) and the examination of vocal behaviours (posture, balance, face and neck muscle activity, respiratory gestures. It also includes objective instrumental measures of maximum phonation time (MPT), jitter, s/z ratios and other relevant acoustic features (intensity, tone, volume pitch). Qualitative instruments which are used to examine vocal quality include the dysphonia Grade, Roughness,Breathiness, Asthenia and Strain (GRBAS) scale as well as the Consensus Auditory Perceptual Evaluation-Voice (CAPE-V) scale.
3. Quality of Life: Additionally, qualitative measures are sometimes used to evaluate the extent to which vocal disorders impact children's social interactions, activities and education. These include the Pediatric Voice Handicap Index (pVHI), the Pediatric Voice Outcome Survey (PVOS) and the Pediatric Voice-Related Quality-of-Life (PVRQOL) instruments.
4. Physical Examination: the physical examination is performed using rigid or flexible endoscopy in order to examine the physiology of the vocal structures.

Treatment

Diagnosis of a voice disorder must be followed by a physician referral in order for a child to have access to therapy services. Treatment of voice disorders in children can involve a combination of behavioral, pharmacological and surgical methods. Behavioural methods are most commonly used to address dysphonia in children, particularly in the case of vocal nodules.

1. Behavioural/ Indirect Treatment Methods: The behavioural approach to treatment uses vocal hygiene as an indirect form of therapy, often supplemented by direct voice production training. This method relies heavily on education and guides children towards the use of vocally safe behaviours, such as hydration. It also explains the need to reduce traumatic behaviours including loud phonation, coughing, imitation of animal and maching noises, hard glottal stops and yelling across long distances. In therapy, children are taught to monitor their vocal behaviour for these signs and are sometimes trained to use an alternative gentle and quiet voice.
2. Direct Treatment Methods: Direct treatment methods are used to facilitate the use of normal voice behaviours in children with dysphonia.
   1. Vocal Function Exercises: designed to improve balance between respiration, phonation and resonance. Exercises include the establishment of correct posture and breathing, increasing the duration of sustained vowels to improve breath support, gliding from low to high pitch to strengthen the crycothyroid muscle and stretch vocal folds, gliding from high to low notes to target the thyroarytenoid musculature, and producing varied notes ( C-D-E-F-G) in order to strengthen laryngeal adduction.
   2. Resonance Therapy: modified form of Resonance Voice Therapy (RVT) designed for children to help facilitate forward focus through exercises required nasal- oral productions.
   3. Semiocclusion of the Vocal Tract: methods that implement semiocclusion of the vocal tract are designed to increase efficient voicing thereby lessening the forceful vibrations of the vocal folds and minimizing mechanical trauma. This allows for the training of safe vocal behaviours, and provides opportunity for existing vocal trauma/lesions to heal sufficiently. Flow phonation therapy, straw phonation and lip buzzes are examples of these methods.
3. Surgical Methods: surgical treatment for certain vocal pathologies is considered when other methods of management have failed and is rarely performed before puberty. If the vocal use is considered a causal factor, these behaviours must be managed before surgery is performed.

References

Relevant bibliography:

Hirschberg, J., Dejonckere, P. H., Hirano, M., Mori, K., Schultz-Coulon, H. J., & Vrtička, K. (1995). Voice Disorders in Children. International Journal of Pediatric Otorhinolaryngology,109-125.

Maia, A. A., Gama, A. C., & Kümmer, A. M. (2014). Behavioral characteristics of dysphonic children: integrative literature review. CoDAS,26(2), 159-163. doi:10.1590/2317-1782/2014408in

Mornet, E., Coulombeau, B., Fayoux, P., Marie, J., Nicollas, R., Robert-Rochet, D., & Marianowski, R. (2014). Assessment of chronic childhood dysphonia. European Annals of Otorhinolaryngology, Head and Neck Diseases,309-312.

Ongkasuwan, J., & Friedman, E. M. (2013). Is voice therapy effective in the management of vocal fold nodules in children? The Laryngoscope,123(12), 2930-2931. doi:10.1002/lary.23830

Reynolds, V., Meldrum, S., Simmer, K., Vijayasekaran, S., & French, N. (2014). Dysphonia in Very Preterm Children: A Review of the Evidence. Neonatology,106(1), 69-73. doi:10.1159/000360841