the british voice association

Voice care

Children get vocal nodules too

by Sara Harris, (specialist Speech and Language Therapist and Locum Team member, Lewisham Voice Clinic); and Lesley Cavalli Cert MRCSLT, (specialist Speech and Language Therapist, Great Ormond Street Hospital NHS Trust, London).


What are Vocal Nodules?

Let's just remind ourselves about vocal nodules, what they are and how they develop. Vocal nodules develop as the result of trauma to the vocal folds. When the vocal folds collide violently swelling can develop around the site of the collision. A single episode of trauma, such as shouting, usually recovers over several days of voice rest, but unfortunately, these episodes are often repeated so the swelling becomes more persistent and requires treatment. These swellings are often described as "soft nodules". If soft nodules are ignored and allowed to progress, the persistent damage may begin to produce fibrous scar tissue. This makes the affected area stiffer and therefore less able to vibrate effectively. When this happens we refer to them as "hard nodules". They are more difficult to treat as they do not resolve with voice therapy and may require surgery to restore the voice. It is important to ask your ENT surgeon whether the nodules are soft or hard as this may make a difference to choosing the most effective treatment.


Nodules on a child's vocal folds

Nodules on a child's vocal folds.



Can children get vocal nodules?

Children can and do get vocal nodules, although it is important to remember that not all hoarseness in children is necessarily caused by vocal nodules any more than it is in adults. When a child develops a hoarse/husky voice it is usually associated with inflammation of the vocal folds from an infection (laryngitis) and the voice is back to normal within two/three weeks. If your child's voice has not returned to normal after three weeks you need to consult your GP for advice. You can request that your GP refers your child to an ENT surgeon, or better still, to your nearest Voice Clinic. The ENT surgeon can examine your child's vocal folds and make a proper diagnosis of the problem. Once the vocal nodules have been confirmed, the ENT surgeon or voice clinic team will help you plan the most effective treatment for your child.


Always investigate!

Hoarseness is simply a sign that your child's vocal folds are not functioning as well as usual. It is a symptom of a problem and that is why a proper diagnosis is so important. Children can develop hoarseness for many reasons just the same as adults can. Sometimes inflammation of the vocal folds (laryngitis) can develop as a result of allergies or occasionally, from asthma inhalers, especially when they are not properly administered. Along with nodules, children can also develop cysts in their vocal folds or a small scar (known as a sulcus).


Don't Panic!

Occasionally more serious problems can occur. Children can be born with or develop a paralysed vocal fold for example, and even more rarely the human papilloma virus can cause warty growths to develop on the vocal folds. Finally, although it must be stressed that it is extremely rare, vocal fold cancer in a child has been reported. No need for panic though, these more serious conditions are very unlikely to happen to your child, they just need to be excluded for everyone's peace of mind, that is all.


Signs and symptoms

Vocal nodules usually develop slowly over time and tend to come and go to begin with depending on the circumstances. If your child's voice is usually clear and sounds normal, the first sign of nodules could be hoarseness developing after your child has been involved in noisy activities such as playing sports, going to parties, or quarrelling with brothers or sisters. At first the hoarse voice usually recovers after a few days, but if these situations occur often you may notice that the hoarseness becomes more persistent. Some children are hoarse during term time but improve with vocal rest over the holidays. Their voices may sound rough and breathy and cut out often, especially at certain pitches. Your child may seem to have to shout all the time. If they try to be quiet the voice may disappear to a whisper. They often sound worse in the morning and take some time to get their voices going. They will also usually sound deeper in pitch than other children.


Clues from the history

Some children are born with obvious voice problems. Their cries at birth and during babyhood are not normal and they are therefore usually diagnosed early as the problem is easy to spot. Perhaps the most common problem with this sort of history would be paralysed vocal fold or some other developmental vocal fold abnormality. Other early voice problems are less easy to spot but with hindsight share a clear history. Mothers typically report these children as being louder and deeper in pitch than other children their age. As their voice use increases with social development, especially when shouting, singing or acting are involved, the voice deteriorates and becomes more persistently hoarse. However, the severity of the hoarseness is variable and often improves with rest. This sort of history would tend to suggest that the child has a cyst rather than vocal nodules.

The more serious problems, such as papilloma, start with a mild but unvarying hoarseness which becomes steadily worse with time. The child is likely to develop difficulties breathing, becoming short of breath or breathing noisily as the papilloma begins to reduce the available space in the airway. These symptoms should be reported to your doctor and investigated immediately.


Treatment Today

In most cases vocal nodules in children can be treated successfully with conservative measures. They may resolve with rest alone in their acute stage if the child rests his/her voice, but if the trauma occurs repeatedly, then treatment will be required. Voice therapy is usually the treatment of first choice. Voice therapy exercises are designed to restore effective voice production so that the vocal fold collision forces are reduced and the nodules resolve. The therapy approach is also likely to involve some behaviour modification around the child's/family's lifestyle, making them aware of situations which are damaging to voices and trying to minimize or avoid them. It is best if the parents are closely involved in the treatment programme. They will need to help determine activities and behaviours that are associated with the voice problem, and to supervise vocal exercises and a reward scheme to reduce episodes of shouting or vocal abuse. Similarly the help of the teacher and school will be needed to ensure that the voice problem is properly understood and that the treatment programme is continued in school time.


My child won't do the exercises!

Some children are unconcerned or unaware that their voices sound hoarse. In fact it is often the teacher or parent who notices the problem initially and is concerned to get it diagnosed and treated. Fortunately, once a diagnosis of vocal nodules is confirmed, it is not life threatening and if your child will not co-operate with the voice therapy and lifestyle changes suggested nothing dire will happen. As your child grows and changes, the nodules and voice problem may resolve on their own. If not treatment can always be carried out later when your child can accept it or is old enough to understand its importance.


Keeping things "cool"

Emotion is a major factor in the development of voice problems in both children and adults. Often it is not the shouting as such that does the damage, but the emotion behind the shouting. Children and parents frequently report that the hoarseness is worse during quarrels and disagreements. Children frequently wind each other up with the things they do and also the things they say. Some children seem particularly susceptible to expressing their rage and frustration through tight and constricted voice use, especially if they are less verbally adept than their siblings. Children also pick up on anxieties and friction between their parents or generally in the family. These situations affect us all at times and it is important to keep alert to our children and pick up when they need reassurance and a chance to talk about real things in a simple way. Try to give them plenty of time to know about and prepare for big changes, such as moves of house or school, deaths in the family or divorce. If you are concerned about your child's emotional state help is available through your GP or local family therapy service.


What happens if the vocal nodules are hard?

Sometimes vocal nodules in children do become hard and fibrous and voice therapy is unable to resolve the voice problem fully. Adults with hard nodules may be offered surgery; however, many surgeons prefer not to offer surgery to children until they have reached adolescence. The reason for this is partly to do with the layered structure of the vocal fold, which develops during childhood but is not fully mature until approx 10 years old. (see "the secret is in the structure" section on vocal nodules in adults). It is also because vocal nodules are not a danger to the child's health and it is safe simply to monitor them until they either resolve or the child is mature enough to benefit from therapy or surgery. Nodules may recur after surgery if the child/young person is unable to improve their vocal habits sufficiently.


Help is at Hand

If your child has symptoms that suggest he/she might have vocal nodules:

  • Seek a medical opinion from a Laryngologist experienced with voice problems. The best solution is to ask your GP for a referral to a multidisciplinary voice clinic – find a Voice Clinic in the UK
  • Whenever possible insist on some quiet time/activities so your child can rest his/her voice and try to keep them away from having to speaking against noise or shout
  • Coughing is often reduced by steam inhalations. They also soothe irritated and swollen vocal folds
  • Keep your child well hydrated and away from inhaled irritants, such as smoke/air pollution/allergens where possible.
  • If your child is a singer discuss suitable warm up exercises with his/her singing teacher
  • If your Laryngologist refers your child to a Speech and Language Therapist take up the option and work hard on the exercises you are given. Voice therapy is like physiotherapy or Pilates for the voice and may well be all your child needs to resolve the nodules.
  • If your Laryngologist suggests surgery, then ask them to explain exactly what they will do at surgery and why they feel it is the best treatment option. Discuss any worries you have openly. It may be the right way to deal with the problem if your child is older, has already worked hard to successfully change their vocal behaviours but the voice problem has not resolved sufficiently. Discuss this with your child's ENT Surgeon and Speech and language Therapist so that you can make a decision you feel is right for your child and then plan voice care after surgery carefully.
Don't blame yourself or your child for it! Vocal nodules are not a crime. They are just an injury that can happen, much as a child can get from playing sports or even in the playground.


This information is intended for guidance purposes only and is in no way intended to replace professional clinical advice by a qualified practitioner.


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