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Column 8 includes various podcast episodes. All episodes discuss pediatric voice disorders and interview a voice therapist. This column provides me with real-world clinical information, and is a good source to see how evidence-based strategies carry over in practice.

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Column 7 includes informational PowerPoints around the assessment, treatment, and general guidelines of various pediatric voice disorders. This column is a helpful resource for me to find quality information prior to seeing a patient.

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Column 6 has different CEU options for me in the future. This column has various CEUs all related to pediatric voice disorders. This column includes CEUs that cover assessment, intervention, and/or a general overview of pediatric voice disorders.

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Column 5 has various referral sources that outline what a report could look like, what to consider when thinking of referring to voice therapy, and an article outlining factors that influence referrals.

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Column 4 has various patient stories. These can be given to families to detail what the experience is like form a patient perspective, but to also help build hop as these are inspirational stories about children finding their voices after their voice disorder.

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Column 3 contains various clinical resources that can be used during assessment and/or treatment. For example this column has different quick screeners with question ideas to ask caregivers and visual aids to be used during therapy to help children identify what a healthy voice sounds like. This column also has handouts for families to help educate them on voice therapy and how to target skills at home.

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Column 2 contains websites with posts written by various health professionals. These sources can be given to families to provide them with evidence-based information from a reliable source in parent-friendly descriptions.

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Column 1 contains scholarly research articles over assessment and treatment of pediatric voice disorders

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EBP: Behavioral Voice Therapy in School-Age
Children with Vocal Fold Nodules

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The Case for Pediatric Chronic Cough - Andrea Storie, M, ClSc, CCC-SLP

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Guest: Andrea Storie, M, ClSc, CCC-SLP - In this episode Michelle is joined by Andrea Storie, MCLSC CCC-SLP, a professional whose focus is on evaluation and treatment of pediatric chronic cough and voice disorders. Whenever a pediatric feeding disorder SLP hears a child cough, instantly our ears perk up and we start wondering, “What is going on in there?” But did you know that some children develop a habit cough that is not triggered by penetration/aspiration? Andrea will educate and inspire us as to the signs and symptoms of pediatric habit cough, the interprofessional team that is needed to diagnose it, and the current evidenced based practice strategies to help treat a pediatric cough.

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More Than a Hoarse Voice - Pediatric Voice Disorders Explained with Lila Griffith, M.S. CCC/SLP

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Season 4, Episode 4: Pediatric Voice Disorders - Play Teach Talk - Podcast

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If your child has a hoarse voice, even if they are 3 or 4 years old, they can be successful in therapy to treat their voice. I go over ways to help your child use their voice in a healthy way and some...

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Sometimes our university training doesn't leave us feeling confident treating pediatric voice disorders. Which makes it intimidating, to say the least, when you're faced with a child with a voice disorder. You might even feel like you've landed in a foreign country where you don't speak the language.

Been there, done that! The good news is

* You know more than you think you do.
* There are lots of accessible resources for you.
* This podcast sheds some light on where to begin and what to consider.

Here's a sample from episode 73
"When you have a client like this, you can go down a rabbit hole investigating what the symptoms of various syndromes are and what the ramifications of this or that surgery are. I did that a little until I realized I wasn't going to find an answer. The answer was to just try. It's like throwing a noodle against the wall to see what sticks."

Tune in to hear a success story about a client with complex communication needs.

--- Useful Links ---
Straw Phonation While Blowing Bubbles
Natural Language Acquisition on the Autism Spectrum (for statistics on "non-verbal" children)

Real Changes in Spoken Language with Sketch and Speak

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: Welcome to The Speech Umbrella, the show that explores simple but powerful therapy techniques for optimal outcomes. I'm Denise Stratton, a pediatric speech language pathologist of 30 plus years. I'm closer to the end of my career than the beginning, and along the way, I've worked long and hard to become a better therapist.

Join me as we explore the many topics that fall under our umbrellas as SLPs. I want to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Hello, welcome to episode 73 of the Speech Umbrella podcast. Before we get into today's topic, I want to put in a plug for the last episode, which was an interview with Dr. Teresa Ukrainetz. I realize that there are some sound distortions in a couple of places that we just couldn't correct, but please don't let that distract you from Dr. Ukrainetz's very important message about teaching children with language impairments to speak with exactness. You know, when you're interviewing online and dealing with bandwidth and internet issues, that's just the nature of the beast sometimes. This is just an occasional problem, but I wanted to let you know that every podcast has a transcription available at thespeechumbrella.com for your convenience.

Okay, so let's move on to today's episode. I'm calling this Pediatric Voice Therapy, Not a Foreign Country After All. Once upon a time I was wary of pediatric voice therapy. I took the view almost that it was a foreign country and I didn't speak the language and sure I had a class in university, but I really didn't know what to do. Then I inadvertently ended up with an honest to goodness voice client and found out it was something I could do. The truth is, the more I learn about our vast field, the more commonality I see among disorders and the more confidence I get that we really do know how to treat the wide variety of disorders that we meet in our field.

Today's episode is all about one client, and an unusual one at that, but his story shares commonality with many clients, and what's really important is that his symptoms and his treatment plan could be effective for a number of clients. Here's what we're going to cover today: a brief definition of voice disorders, the background of this client who I'm calling Sam, the connection between motor movement and voice, my treatment plan and the outcomes. Here's what I hope you get from today's episode, the confidence to work with voice issues in the pediatric population.

Now, I fully recognize there are particular situations in which a client needs a super specialist. We have SLPs who work very specifically with vocal performers and who themselves have a background of vocal performance and that's not the kind of voice therapy I'm referring to. Sam is a child with complex communication needs and he just needed an SLP to look at the whole child and find the root of his problem. If I can do it, you can do it. Now what a difference it has made for Sam.

So what is a voice disorder? This is straight from ASHA's website: a voice disorder occurs when voice quality, pitch, and loudness differ or inappropriate for an individual's age, gender, cultural background, or geographic location. So as they describe Sam, you'll see that a voice disorder does fit Sam's condition, although he has many diagnoses.

This story begins when Sam's mother contacted me, she had heard about PROMPT therapy and thought Sam might learn to speak a little bit more with this approach. At this point, he had a few spoken words, he signed and he used a communication device. Sam has been diagnosed with Smith-Magenis Syndrome with Autism Spectrum Disorder as an infant. He had laryngomalacia, he's been diagnosed with Choanal Atresia, and that's just a partial list, so you get the idea. Complex communication needs and health issues. He has had extensive surgeries to open and repair his airway. He had surgery to correct a lip and tongue tie, and on the case history form his mother noted his voice quality and that he really had too many surgeries for her to list.

But when I saw this kiddo, he had decent articulation placement skills, but little or no true phonation. So when he did speak, it came out in a whisper. He could scream. So that was a good sign that he had phonation on a reflexive level. And I saw a child who was very motivated to speak, but didn't have the motor ability to use his voice.

When I say decent articulation placement skills, I mean, he could whisper or say a number of early consonants, like the D, the T K G H Y, and even S. Significantly, he couldn't say M or N. When you have a client like this, you can go down a rabbit hole investigating what the symptoms of various syndromes are and what the ramifications of this or that surgery are, and I did that a little bit until I realized I wasn't gonna find an answer.

And the answer was to just try. It's like throw a noodle against the wall and see what sticks. Now here's what I did know. 40% of kids on the autism spectrum disorder who have been considered nonverbal are severely challenged with motor planning. And Sam was challenged with motor planning and his movements were slow and stiff and uncoordinated. He had not been receiving OT or PT for some time because of Covid interrupting those services. I knew he had reflexive phonation, which was evident when he yelled, and it was quite powerful. As his mom put it, he has a set of pipes, but he didn't have voluntary control of that phonation. He had decent motor planning for his lips and his tongue, but his jaw was really stiff as far as opening and closing. That's understandable because he also had surgery on jaw. His attempts to imitate words were impressive, even though they were whispered.

So I felt one of the keys to his speech was happening below the vocal folds. The key to his speech was in his core, because he was so stiff when he moved. He really didn't bend over very well. He didn't bend from the knees. He couldn't hop, he couldn't run. He needed to move to excel and to pair his exhalations with voicing. So here's the game plan I made. I needed to educate his parents about the vital importance of PT and OT therapy and how the core powers the voice. And by the way, his mom did get him into physical therapy.

I needed to do lots of physical activity with him. He loved to play basketball, so that was great. And take advantage of his exhalations and shape them into voiced utterances. So when we played ball, not just basketball, all kinds of balls, he retrieved all the balls in our games. because that movement helped him so much, just bending down and having to get the ball and at first he'd look at me like, you're gonna get it. I'm like, no, you get it, Sam. That was kind of great. I didn't have to run around the room picking up the balls. Sam got to do it. I want to mention here that I have treated many children who have had some degree of difficulty with voluntary phonation, and some running and some jumping, imitating animal sounds and such was enough to help them access their voices.

In my mind, I didn't actually categorize them as voice clients, because we moved so quickly from that stage, from that phonation stage to working on articulation goals. But as we see in Sam's case, it's not exactly clearly defined. When are we doing voice therapy? When are we doing articulation with a client like him?

And it really doesn't matter so much as long as you're treating their symptoms. With Sam, I realized he needed more than the physical movement to work on his core. He also needed to get his vocal folds working. And by the way, his mother told me to go for it as far as voice therapy goes. And Sam's ENT said he didn't have vocal fold damage, so I was good there. I did my due diligence there. Here's where I felt a bit intimidated, and here's where I first realized I needed a really specific technique for voice therapy. So I went to ASHA's website. I found semi occluded vocal track exercises, which sounded like that would be the right thing for Sam, and I dove in, so that sounds really long, right?

Semi-occluded vocal track exercises. Well, they involve narrowing at any superglottic point along the vocal tract in order to maximize interaction between vocal fold vibration, that's sound production, and the vocal tract, the sound filter, and to produce resonant voice. Okay, that sounds really intimidating. Just reading that sounded a little intimidating to me, but in reality, if you can teach a kid to lip trill and to blow bubbles in water with a straw, you are doing semi occluded vocal tract exercises. Those were the two main exercises that I chose to do. That's not a complete list of what you could do. I needed to start with large diameter straws because he couldn't blow bubbles with a regular straw at first.

And I got those online and I got plastic ones that were reusable. And so that's where we started. And from there we graduated to regular diameter straws. There are a number of videos on YouTube demonstrating how to do straw phonation so there, I'll just direct you there. And lip trills, well... that's a lip trill, okay? You don't need a YouTube video to show you how to do a lip trill. And other things I did, and some of these I'm still doing, I used bite blocks to help him open his jaw wider. And if you're not familiar with bite blocks, they're a series of gradually larger and larger blocks that you can stick in a client's mouth, one on each side to help them get their jaw more and more open.

Which he couldn't do it first, his jaw was really, really stiff. And now he can have the largest bite blocks in his mouth and he can say, ah, and I can even take them out. And he can still open his jaw wide and say, ah, so that's great. And his ah, sound is more consistent. It's stronger because he can open his jaw wider that just helps it.

And we've also practiced just saying the mmm sound, the M sound and prolonging it. And first that was really, really hard for him, but I still remember the first day he said a really clear M with true phonation, it didn't come out all hoarse, it didn't come out all strangled sounding. It was just a really beautiful, clear, mmm, and it was just a sound I had never heard from him before.

And so we walk into the waiting room after the session was over and he says mmm for his mom and she almost started crying. It was just like, that's your voice, that's your real voice. And by the way, we are still working on the mmm sound because he can't say it in very many words yet. It turns into a b sound instead of the mmm, but we are working on it.

And it's just amazing that he can even say an mmm, it was so hard to get here. Some of the other things that have worked, I found, um, that a stiff foam ball, when he pushed it together with his hands, that engaged his core and he said the word push and he actually said it with phonation, just because of the effort he was making when he was pushing the sides of the ball in.

And so that was just the accidental discovery cuz we were playing ball. And I was like, oh, okay, we are gonna do this. And then I used his vowels that he did have to shape other vowels. So ooh was one of the first vows he could say and truly use his voice with it. And if you can drop your jaw a little bit, ooh becomes ohh. He could also say, uh, rather early on, and as I taught him to drop his jaw, uh, turned into ahh, again, using the bite blocks, that helped too. And really the secret to his ahh, besides the bite blocks, he was imitating a monkey. One day we were doing a monkey puzzle and he did a ooh-ooh ahh-ahh, kinda like that, the ahh was barely there.

I was like, oh, we are so doing this monkey puzzle over and over and over again. And he just got better and better. Ooh-ooh ahh-ahh, ooh-ooh ahh-ahh, until the ahh became really strong and then he could separate the ahh from the ooh. Many of these discoveries I made just as things happened in the therapy session and then I took advantage of them and grabbed onto them and say, we are gonna do this again because this is working.

And now that he can say ahh, He can say bah for ball, which is a word he couldn't say before, but he absolutely loves to play ball, so that's so helpful for him. This took a lot of patience. I realized it only took me a few minutes to describe it, but this was incremental. Tiny, tiny steps a little bit at a time as his voice begin to emerge, and it's still an ongoing process, but he's building endurance now. He's stringing sounds together. For example, the ABCs. His mom sent me a video of him singing the ABCs in the bathtub, so I can't share it with you, but talk about a happy little boy. He is singing at the top of his lungs and his voice isn't breaking after A, you know, his A, B, C. He's getting three or four sounds in a row before his voice breaks and then he is coming back in.

So that was just amazing to hear. Counting. He loves to count as a child on the spectrum does, loves ABCs, loves the numbers, so he is stringing words together. He's maintaining phonation. We still have a ways to go. As I said, M is still hard in some words, N is not a sound he can say yet, but we're just working on it.

He is speaking often. He often puts three words together. His voice kind of comes and goes, but he's just improving. He's really a vocal communicator now, and his behavior has improved so much. I don't know the last time I saw a tantrum and they used to be pretty frequent in the therapy room, I know that he still has some tantrums at home, but hey, he's a kid. He now prefers speaking over signing or using his communication device, and I never, ever discouraged that. I always signed with him if he wanted to sign, but he just finds it more efficient to speak now. He learns vocabulary without being taught. He just absorbs that. And so he's an efficient communicator. Using his voice makes him happy.

So here's the takeaway. Always look at motor issues when you're faced with a nonverbal client or clients who can't access their phonation. And when you're faced with a client with complex communication needs and with maybe some voice therapy needs, you can do this kind of therapy. The resources are out there. They're on ASHA, and it shares ground with so much that we already know how to do. I mean, the lip trills, and the straw blowing phonation, and just the moving around the room, those are all things that we can do. And all we had to do with him was just understand that we take this little tiny success today and we build on it and we take this little tiny success and we build on it some more, and that's what we do every single day.

So it was not as intimidating as I thought it would be, and it has had a huge, huge effect on Sam's life. So taking my tagline, when you master the simple, the complex takes care of itself, well, Sam has complex communication needs and health issues, but the treatment, the treatment was so simple. Lip trills, straw phonation, working on the mmm sound, building endurance... Truly, when you master the simple, the complex does take care of itself. Thanks for listening and talk to you next time.

Thanks for listening to The Speech Umbrella. We invite you to sign up for the free resource library at thespeechumbrella.com. You'll get access to some of Denise's best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level. All this is for free at thespeechumbrella.com. If you've enjoyed this podcast, subscribe and please leave us a review on Apple Podcasts and other podcast directories.

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Pediatric Voice Therapy-Not a Foreign Country After All

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Sometimes our university training doesn't leave us feeling confident treating pediatric voice disorders. Which makes it intimidating, to say the least, when you're faced with a child with a voice disorder. You might feel like you've landed in a foreign country where you don't speak the language.

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voice therapy - Podcast Episodes - Speech Uncensored

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All Podcast Show Notes Aphasia Burnout Cognition Communication/AAC COVID-19 Conversations Critical Care Dysphagia Neurodegenerative Disease Pediatric Topics Representation Matters Voice Work Life The One Thing Series How I Practice Series

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Ep. 51: Strategies for Voice Disorders to Facilitate Vocal Health in School-Aged Children - Jayanti Ray, PhD, CCC-SLP | The Speech Link: A Speech Therapy Podcast

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Guest: Jayanti Ray, PhD, CCC-SLP - In this one-hour course, Dr. Ray shared the common signs, symptoms, and conditions that impact voice disorders in school-aged children and therapy techniques to mitigate them. In addition, she covered the importance of vocal health and several ways maintain vocal quality and agility in children.

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‎More than Child’s Play: More Than a Hoarse Voice - Pediatric Voice Disorders Explained with Lila Griffith, M.S. CCC/SLP auf Apple Podcasts

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‎Sendung More than Child’s Play, Folge More Than a Hoarse Voice - Pediatric Voice Disorders Explained with Lila Griffith, M.S. CCC/SLP – 23. Mai 2021

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Raspy Voices in Children: When To Worry | TherapyWorks

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You know the way your voice sounds when it’s allergy season, you just went to a concert, or are feeling under the weather? Some children may have the same

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What Is Vocal Cord Dysfunction (VCD)?

Vocal cord dysfunction means that the vocal cords partially close during breathing, so air has more trouble getting through. The vocal cords are two pieces of tissue stretched across the voice box. They vibrate to make sound when a person speaks.

Vocal cord dysfunction is also called paradoxical vocal laryngeal dysfunction or paradoxical vocal fold movement.

What Are the Signs & Symptoms of Vocal Cord Dysfunction (VCD)?

A child with vocal cord dysfunction may:

have trouble breathing, especially when breathing in (inhaling or getting air in). This can be scary and need medical care.

cough or clear the throat

wheeze or make raspy sounds during breathing

be hoarse or have other voice changes

have chest pain or throat tightness

The symptoms of vocal cord dysfunction almost never happen while a child is sleeping.

What Causes Vocal Cord Dysfunction (VCD)?

Children with vocal cord dysfunction have "triggers." These are things or situations that they're very sensitive to. The trigger makes the vocal cords partially close, which causes breathing problems.

Common triggers include:

infections, such as a cold or the flu

irritants in the air, such as perfumes, pollution, dust, pepper, etc.

exercise and other physical activities, like dancing, playing hard, or jumping around

stressful situations, such as worrying about school or family problems

Allergies and acid reflux (chronic indigestion) can make vocal cord dysfunction worse.

Who Gets Vocal Cord Dysfunction (VCD)?

Most children with vocal cord dysfunction are 6 years of age or older. It happens more often in girls than boys.

How Is Vocal Cord Dysfunction (VCD) Diagnosed?

To diagnose vocal cord dysfunction, doctors will:

do an exam

ask about the symptoms

Doctors also use tests such as:

spirometry and pulmonary (lung) function tests: to measure how fast and how much air flows during breathing

laryngoscopy: to see the vocal cords using a tiny camera on the end of a thin tube

a challenge test: to make symptoms happen while the doctor looks at the vocal cords. To start symptoms, the child may run on a treadmill, ride a bike, or take a special medicine.

The symptoms of vocal cord dysfunction and asthma can be similar. So doctors will check to see if a child has vocal cord dysfunction, asthma, or both.

Vocal cord dysfunction is the most likely cause when:

The breathing trouble happens during exercise. (In exercise-related asthma, symptoms tend to happen soon after exercise.)

The doctor hears wheezing sounds coming from the child's neck when listening with a stethoscope. (In asthma, the wheezing sounds come from the chest.)

Medicines that usually work well for treating asthma do not help the child's breathing.

How Is Vocal Cord Dysfunction (VCD) Treated?

Vocal cord dysfunction is treated by an ear, nose, and throat doctor (ENT, also called an otolaryngologist), a pulmonologist, and a speech therapist. They work together to help the child learn to relax the vocal cords while breathing.

Treatment for vocal cord dysfunction may also include:

practicing breathing exercises

using biofeedback

avoiding irritating fumes or dust

staying hydrated to help the vocal cords work well

The doctor may recommend medicines to treat allergies or acid reflux if they make the vocal cord dysfunction worse.

If stress plays a role, the ENT doctor may ask a psychiatrist or psychologist to join the treatment team. They can help the child understand the cause of the stress and learn the best way to handle it.

Looking Ahead

With practice, most kids with vocal cord dysfunction can learn to avoid triggers, relax the vocal cords, and manage stress to help ease or stop symptoms. Sometimes symptoms come back and the health care team will start treatment again or use a different treatment.

Date reviewed: January 2019

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Vocal cord dysfunction (VCD) means that the vocal cords partially close during breathing, so air has more trouble getting through.

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Encouraging your child to produce a healthy voice

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Procedures and treatments from Great Ormond Street Hospital on Encouraging your child to produce a healthy voice

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Information for Families: Vocal Nodules in Children

Details

Created: Saturday, 03 December 2011 16:48

Updated on Friday, 02 March 2012 12:22

Speech-Language Pathologists / Speech and Language Therapists (SLPs/SLTs) do not treat vocal nodules or hoarse voices in children or adults until the person's larynx (voice box) has been examined by an Ear Nose & Throat (ENT) specialist. It is the ENT specialist's task to determine the medical reason, if any, that a person has voice symptoms such as hoarseness or frequent loss of voice. This examination is called laryngoscopy.

Laryngoscopy usually occurs in the ENT specialist's consulting room. Sometimes it is done under general anaesthetic.

The ENT specialist may find a problem that requires a surgical or medical solution (i.e., not speech pathology treatment). On the other hand, they may find a problem that is best treated by a SLP/SLT. Alternatively, surgery and voice therapy may be required.

If necessary, having performed the laryngoscopy, the ENT specialist informs the SLP/SLT of what he or she observed, and diagnosed, in the patient's larynx (e.g., normal structure and function, reddened vocal cords, laryngitis, vocal nodules, a paralysed vocal cord, bowing of the cords, vocal polyps, granuloma, etc). From this information the SLP/SLT can determine the appropriate course of speech pathology intervention (treatment).

The following notes notes relate to the SLP/SLT management of children with nodules or voice strain.

Detailed case history

Once the child has had an ENT examination, speech-language pathology assessment can commence. As part of the initial process, the speech-language pathologist needs to take a very detailed case history, which can involve asking parent/s some very searching and personal questions. These questions cover areas such as the child's early development, the way they get on with other people, relationships within the family including the way family disputes are resolved, behaviour management, peer relationships, health history including allergies, and the child's personality.

Treatment

The overall aim of voice therapy is to teach a healthy, non-abusive voice production pattern. The speech-language pathology treatment of nodules and vocal strain in children begins by educating the child and his or her family about the nature of the problem, including its signs and symptoms, causes and risk factors.

It is helpful for the child and family to understand the normal anatomy and physiology of the larynx ("voice box"), in relation to the child's specific laryngeal pathology (e.g., nodules, thickened vocal cords, etc).

The potentially damaging effects of tension and strain upon the larynx due to forcing the voice need to be explained to the child and his or her family.

The child is taught about voice production: phonation (how the sound is produced by the vocal cords); respiration (breathing); and, resonance.

The idea of adequate breathing patterns are explained, and the child is helped to "feel" the sensations of appropriate breath support sitting, standing and lying down.

They are shown how to check that the level of the thyroid notch does not rise excessively during gentle humming (e.g., "hmmm, ummm, hummm...").

They also learn to palpate (feel) their own necks, or to look in a mirror, for excessive neck muscle tension around the larynx.

Finally, the child learns, by imitating the therapist, how to produce resonance in different parts of the vocal tract: e.g., "chest" voice, "head" voice, and "nasal" voice, and front and back oral resonance.

This voice training provides a foundation for learning to produce the best voice with the least effort.

Resonance training is especially important, since it helps if children with abusive voice production habits can be taught to "project" their voices to achieve increased loudness, rather than using a loud strained voice.

Throughout therapy children are encouraged to remember that: "If your voice sounds good, you are using it a healthy way".

The term 'hyperfunctional' means 'overused'. Hyperfunctional voice disorders, and laryngeal pathology such as vocal nodules almost always result from some form of vocal abuse or misuse. It is therefore essential to identify abusive behaviours (hence the need for detailed case history taking at the outset of therapy) and reduce or eliminate them, so that the cords can heal and recover, allowing a return to normal voice.

Simple voice exercises, performed morning and evening, are helpful in many cases in "warming up" and "cooling down" the voice. These exercises are outlined and supervised, according to the particular patient's needs, by the speech-language pathologist.

Reference

Glaze, L.E. (1996). Treatment of voice hyperfunction in the pre-adolescent. Language, Speech & Hearing Services in Schools, 27, 3, 244-250.

The signs and symptoms of childhood nodules or vocal strain include one or more of the following:

1. dysphonia, which is a hoarse, breathy or rough voice; or a voice with excessive 'glottal fry' (a 'croaky' characteristic that very old voices sometimes have, but which is not normal in young voices)

2. intermittent aphonia, which is a recurring temporary loss of voice, especially first thing in the morning and at the end of the day, or after specific events such as sports day

3. voice breaks, which are fleeting interruptions to the voice, during speech or singing, as though it "cuts out" for a second

4. pitch breaks, which are fleeting, abrupt changes in the pitch of the voice, during speech or singing, usually from a lower note to a higher note

5. an excessively loud voice, this requires no explanation. Every family has a "built-in" appreciation of how loud is too loud.

6. an inability to sustain a note when singing, in which the voice wavers or cuts out.

7. an effortful or strained voice, in which the person sounds as though producing voice requires special effort: their voice-production does not seem to be efficient.

Voice strain and nodules are caused by stress to the larynx, within which are the delicate vocal cords. This stress is generally referred to as "vocal abuse".

It is rare to find just one "abusive" behaviour producing voice symptoms.

Classically, children with nodules are in the habit of talking too long, too loudly and with too much effort.

Usually children develop vocal nodules or vocal strain due to the interaction of two or more of the following, done to excess:

1. talking and singing, for example: excessive and over-enthusiastic rehearsal of school plays or concerts; excessive choir or solo-singing practice; overusing the voice on school camps or excursions; shouting in the playground; talking and shouting against background noise, such as in a swimming pool; overusing the voice during an infection such as a head cold; cheer leading; and overusing the voice when tired or emotionally upset. Lengthy talking, even at normal rate and volume, but without a quiet "recovery time" can also contribute to vocal strain and nodule formation.

2. glottal attack, sharp glottal attack and forceful use of the voice can seriously damage the vocal cords.

3. coughing, and loud, forceful sneezing: many children with nodules do not rest their voices when they have upper respiratory tract infections, even when their throats are sore. Coughing and sneezing can be particularly problematic for a child with asthma or a post nasal drip.

4. crying, laughing and loud or prolonged outbursts of emotion: for example, even very young children who tantrum frequently can develop nodules. Inappropriate or unresolved coping mechanisms for negative emotions (anger, fear, sadness, nervousness) can lead to bottled up anger, explosive outbursts or irrational behaviour, accompanied by loud, forceful voice use.

5. shouting, cheering and screaming: one loud episode at a sporting event or pop concert is sufficient to produce an episode of aphonia.

6. grunting : grunting while load-bearing, for example in a rugby scrum or while weight training, puts a sudden shock through the vocal cords as they "fix" into position to create a vacuum in order to "take the weight".

7. throat clearing: the chronic throat clearing associated with post nasal drip puts a constant strain on the vocal cords, which are g-r-o-u-n-d together each time the throat is cleared.

8. making sound-effects: Dalek, explosion and monster noises, especially if they are made while breathing IN (!) put a tremendous strain on the cords, as can assuming character accents, for example Power Rangers, Rambo, Street Sharks, and macho villain and "tough guy" impersonations, and using excessive and deliberate glottal fry when speaking.

9. dryness: the overuse of certain medications, such as cough lozenges, antihistamines and patent "cold cures", especially in conjunction with voice overuse, infections or allergy dries out the delicate lining of the larynx and vocal cords, making voice symptoms worse. Caffeine (e.g., in cola) can act as a diuretic, adding to drying effects. Mouth breathing is also potentially drying.

10. restricted fluid intake: for a healthy respiratory and vocal system good hydration is necessary. A simple way of checking for adequate fluid intake is to ensure that urine is pale in colour.

Some children are more vulnerable to developing vocal nodules and vocal strain than others. Children who are more at risk may have one or more of the following:

1. a family with loud voice habits such as yelling around the house and calling from room to room in constant background noise. Some children with vocal problems have developed habitually loud voices simply in order to "get the message across" in a constantly loud household.

2. chronic asthma and/or allergies (including post nasal drip and allergic rhinitis); and incorrect use of some puffers (i.e., no spacer and/or drink of water when they are recommended)

3. recurrent and frequent upper respiratory tract infections including infected tonsils, sinuses, adenoids and throat

4. gastric reflux

5. affective disorders such as attention deficit disorder and hyperactivity, or a "temperamental personality"

6. behaviour problems

7. excessive stress or tension in the child's life, due to internal factors (within the child), external factors (within the environment) or interpersonal factors (e.g., conflict or competition)

8. a loud, outgoing, enthusiastic, competitive personality with a tendency to "act out" emotionally (their parents can often remember them as terrible "terrible two's" who tantrumed loud and long and who could whinge endlessly). Some babies just seem to be born loud and lovable, and grow into loud and lovable toddlers and children, some of whom are, unfortunately, 'at risk' for voice problems.

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speech sound disorders; speech-language pathology; evidence based practice; ebp; speech and language therapy; communication; phonological disorder; childhood apraxia of speech; cas; developmental verbal dyspraxia; articulation; lisp; slp; slt; caroline bowen

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Information for Families: Vocal Nodules in Children

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Trustworthy SLP/SLT information with a focus on children’s speech sound disorders / clinical phonology.

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Advice for Parents: Children with Vocal Abuse

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Clearly Speaking:
Pediatric Voice Disorders

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Pediatric Voice Therapy:
Evidence Based Practice…and Everything Else

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Enhancing Clinical Practice With Effective Stroboscopy Interpretation

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This session describes how to evaluate stroboscopy results using a new visuoperceptual assessment tool-the Voice-Vibratory Assessment with Laryngeal Imaging (VALI) rating form. The speaker also discusses how to integrate the results from stroboscopy intro treatment planning and execution. This course is a recorded session from the 2020 online conference "Voice Evaluation and Treatment: Improving Outcomes for Children and Adults."

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Accessible, Low-Cost Methods for Voice Assessment

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This session shares low-cost and accessible methods for voice measurement that clinicians in any work setting can use as part of a voice assessment for adults and children. These assessment methods address the impact of vocal issues on activities of daily living, allow individuals to report voice changes over time, and aid clinicians in developing treatment goals and measuring outcomes.

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This session focuses on the assessment of pediatric voice disorders, including techniques for successful laryngeal visualization with children, differential diagnosis of vocal pathologies in the pediatric population, acoustic/aerodynamic measures of vocal function, and implementing a multidisciplinary approach for evaluation and treatment.

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Voice and Swallow Clinics Lecture Series

Welcome to the University of Wisconsin Division of Otolaryngology, Voice & Swallow online courses! Our Voice & Swallow Clinics Lecture Series is comprised of expert lectures recorded live during private offerings held at the UW Voice and Swallow Clinic. They are courses you can take that are eligible to earn ASHA CEUs.

There is NO CHARGE from UW for these offerings. Work at your own pace from your office or home to take these courses! Voice & Swallow Clinics Case Conference and Lecture Series is sponsored by the University of Wisconsin School of Medicine and Public Health Department of Surgery.

Register for our online Case Conference and Lecture Series, view a lecture and complete the related assessment of learning.

Non-ASHA members do not need to register and may select a course and click "watch now" to review a lecture.

ASHA members tracking CE credit independently should register and retain a copy of their completion certificate for their records.

ASHA CEUs are awarded to those that meet eligibility criteria by the ASHA CE Registry upon receipt of the CEU Participant Form from the ASHA Approved CE Provider. The ASHA CE Registry is a computerized data base that awards CEUs on behalf of ASHA's Continuing Education Board. Participants pay an annual fee to use the ASHA CE Registry. Please allow up to 6 months for the course to appear on your ASHA transcript.

Please visit the FAQ if you have any questions about these courses.

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Voice and Swallow Clinics Lecture Series

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Voice and Swallow Clinics Lecture Series Welcome to the University of Wisconsin Division of Otolaryngology, Voice & Swallow online courses! Our Voice & Swallow Clinics Lecture Series is comprised of expert lectures recorded live during private offerings held at the UW Voice and Swallow Clinic.

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"I enjoyed the therapy techniques." P.T. (Apr. 2024)

"The concept of negative practice is something I've been missing in my practice that should be helpful. The instructor was very clear and concise." T.W. (Mar. 2024)

"Treatment-specific recommendations were beneficial. I liked the accessibility, treatment methods, and presenter knowledge." K.P. (Jan. 2024)

"I found this method very functional and easy to use. I will be able to use this in my daily practice since I have been receiving more OP voice referrals." S.B. (Dec. 2023)

"Old vs. new voice was a beneficial topic. I liked the therapy treatment videos." B.O. (Nov. 2023)

"I liked the hierarchy of voice treatment and goals." T.W. (Sep. 2023)

"Learning about blocked and random, twang, and new & old voice were helpful. I liked the clinical examples and experiences." A.T. (Sep. 2023)

"I liked having the patient demonstrate "old" vs "new" voice for training purposes. Confirmation of my treatment methods being effective and up to date." J.T. (Jun. 2023)

"The new/old voice contrast was beneficial. I liked the example clips." A.M. (May 2023)

"I liked the actual case scenarios and examples provided in this course." J.M. (Apr. 2023)

"Very applicable to my practice, and right away. Learning random practices with new and old voices were beneficial." E.T. (Mar. 2023)

"Provided treatment techniques associated with various disorders of voice." A.J. (Feb. 2023)

"I liked the stimulability testing and the video/audio examples." A.J. (Feb. 2023)

"Great approach to therapy with a complete toolbox. I liked the therapy techniques, client education, treatment hierarchy, and stabilizing the "new" voice through random practice. All content was very informative." L.H. (Dec. 2022)

"I liked the video samples. This course was well structured and clear. Learning the importance of planned contrast between old and new voice at all levels of the hierarchy." K.D. (Dec. 2022)

"Valuable information. Testing for stimulability was beneficial." S.G. (Dec. 2022)

"Learning voice techniques and how they are applied to improve specific voice impairments. I liked the course format with practice and breaks." T.H. (Nov. 2022)

"Practical and patient-centered approach. I liked the blend of models, the treatment hierarchy with blocked vs random, etc. This is great for carryover." C.H. (Oct. 2022)

"I loved the videos and all of the tips and techniques reviewed. I liked the structure and how all areas of the model were introduced and everything was explained clearly." B.R. (Oct. 2022)

"Clear objectives and targeted instructions. I liked the treatment hierarchy." J.S. (Oct. 2022)

"I liked the examples used by the clinician to demonstrate the particular voice disorder discussed. She did this by her own imitation and by videos of clients." E.B. (Sept. 2022)

"Learning the importance of educating the client each step of the way." E.B. (Sept. 2022)

"The video recordings/examples of each scenario were good. Liked application and demonstration of each technique and component of the GVTM." M.M. (Aug. 2022)

"I liked the video examples." M.B. (Aug. 2022)

"Very specific and detailed description with good examples." J.M. (Jul. 2022)

"The course is very practical. Liked the stimulability, various techniques to try." D.F. (Jul. 2022)

"Very clear presentation with great demonstrations - comparing techniques for voice work for specific voice problems." S.A. (Jul. 2022)

"I will utilize this info in my new job in outpatient with voice patients. I liked the case studies and examples of treatment sessions." I.S. (Jul. 2022)

"I liked the discussion of how to systematically incorporate elements of motor learning while also remaining gestalt or holistic in voice therapy to get quicker patient-centered outcomes and generalization." Z.C. (Jun. 2022)

"I liked the concept of random practice, analogous to stuttering therapy. Also the presenter demos, plus the video and audio samples of her work with actual patients." A.C. (May 2022)

"Some great take-a-ways to use with my adult clients. I liked the use of multiple strategies." L.N. (Feb. 2022)

"Loved the clips of actual sessions." S.H. (Feb. 2022)

"I liked the application of the GVTM model - utilization of the various stimulability and therapy approaches - demonstration of the different stimulability techniques and approaches along with the descriptions of when they are often used and helpful." S.S. (Jan. 2022)

"I liked the specific treatment program, and the ease of course access." S.F. (Jan. 2022)

"The course was structured to be practical and make sense. I liked the blocked and random practice and hierarchy." J.D. (Dec. 2021)

"I liked the examples of voice techniques and hierarchy to help promote learning and self-awareness." L.R. (Dec. 2021)

"I enjoyed the actual focus on real life application of the GVTM to assessment and treatment of patients. The concept of old vs new voice and how to get the client to achieve generalization of new voice in a short period of time for improved quality of life." T.G. (Dec. 2021)

"I liked the client videos and the discussion on not focusing on the articulatory specifics (just the sound)." S.R. (Dec. 2021)

"I appreciated the flash case descriptions at the end, since this allowed us to reflect quickly, as in a therapy situation, on how to proceed following all the components and strategies learned in the rest of the training." J.M. (Dec. 2021)

"How to achieve generalization of new voice by practicing "new" vs. "old" voice in each step of the treatment hierarchy was the topic most beneficial for me." A.C. (Nov. 2021)

"I liked everything! Great ideas! And I liked the case scenarios." C.O. (Nov. 2021)

"I really liked the variety of voice therapy techniques...excellent work at combining various techniques depending on each client's needs. I appreciated the global approach of the voice therapy procedure." I.K. (Nov. 2021)

"Liked that she broke down the different methods that could be used to treat voice disorders and how to implement them with clients." C.M. (Oct. 2021)

"Gave me new approaches for structuring sessions and home practice with my clients. The examples of the voice techniques were good." S.S. (Sept. 2021)

"Superb video and audio examples - all were of sufficient length to give listeners a good sense of the procedure as well as ample time to see an expert applying them with real people. Also very much appreciated the detailed listings of elements of respective pieces of service delivery (ex: vocal hygiene examples)." D.D. (Sept. 2021)

"I liked everything about the random practice to produce the new and the old voice. It will change the way I will bring consciousness of the old vs the new voice of the patient. I really like all the examples (video and audio). It was really helpful." S.C. (Aug. 2021)

"I enjoyed learning about voice techniques that I had minimal experience incorporating into daily practice. And it was helpful for my setting." E.B. (Aug. 2021)

"I found talking about the treatment portion the most beneficial because all the steps were explained, and examples were given of what it might look like in the clinical setting." L.U. (Jun. 2021)

"The course was excellent both from the research to the outlined treatment program. The video and audio presentations were also most helpful as examples of the outlined hierarchy of the GVTM voice therapy model." A.B. (May 2021)

"I liked the video clips, it really helps to see it in action." D.E. (Feb. 2021)

"I appreciated the discussion on treatment hierarchy. Her examples of treatment will help me with my patients. I really like her system. Presenter was thorough with defining and explaining treatment strategies." C.R. (Feb. 2021)

"I really enjoyed seeing the presenter and her examples as well as the case study videos...they were excellent! I am a very visual learner so this helped with my understanding on how to implement and think about therapy." R.R. (Jan. 2021)

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Voice Disorders And Speech Therapy | Online SLP Training

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Voice therapy for children and adults using the Global Voice Therapy Model (GVTM). Offered for 0.2 ASHA CEUs.

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Pediatric Voice Therapy Part 1: Introduction to Pediatric Voice Disorders

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Part one of this four-course series will provide an introduction to pediatric voice disorders. Part one will introduce participants with an overview of normal pediatric anatomy and physiology, pediatric laryngeal development, and voice production. This section will also present information regarding...

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National leader of continuing education for therapists. In-person, live streaming, live webinars, online videos, and online text courses offering CEUs for PTs, OTs, and SLPs.

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 Factors influencing referral of patients with voice disorders from primary care to

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(Cameron Cottrill for The Washington Post)
Share Comment Save
Vivienne Weil was an unusually quiet baby.

"She never cried loudly enough to bother us," recalled Natalia Weil of her daughter, who was born in 2011.

Although Vivienne babbled energetically in her early months, her vocalizing diminished around the time of her first birthday. So did the quality of her voice, which dwindled from normal to raspy to little more than a whisper. Vivienne also was a late talker: She didn't begin speaking until she was 2.

Her suburban Maryland pediatrician initially suspected that a respiratory infection was to blame for the toddler's hoarseness, and counseled patience. But after the problem persisted, the doctor diagnosed acid reflux and prescribed a drug to treat the voice problems reflux can cause.

But Vivienne's problem turned out to be far more serious - and unusual - than excess stomach acid. The day she learned what was wrong ranks among the worst of Weil's life.

"I had never heard of it," said Weil, now 33, of her daughter's diagnosis. "Most people haven't."

Dwindled to a whisper

At first, Natalia, a statistician, and her husband, Jason, a photographer, were reassured by the pediatrician, who blamed a respiratory infection for their daughter's voice problem. Her explanation sounded logical: Toddlers get an average of seven or eight colds annually.

Weil said the couple assumed Vivienne's voice would return to normal - and didn't want to overreact.

"We were first-time parents and we were worried," Weil said, "but thought maybe we worried too much and should wait. We decided to give it time. We didn't know how much children were supposed to talk at the age of 1 or 2. . . . We just did what the doctors told us."

But Vivienne's paternal grandmother grew increasingly concerned. Because Vivienne was slow to talk, her grandmother wondered whether she might have a developmental delay or a speech problem and suggested an evaluation by a speech pathologist.

During a visit in September 2013, the pediatrician prescribed a liquid antacid for the 2½ -year-old. The doctor also approved a referral to an ear, nose and throat specialist.

An ENT who saw Vivienne soon afterward diagnosed her with dysphonia - an impaired voice that can result from a problem with the vocal cords. He sent her to a pediatric otolaryngologist for a more complete evaluation.

The pediatric specialist listened to her breathe and talk and then scheduled a laryngoscopy. The test involves a visual inspection of the back of the throat. In some cases, doctors use a thin, flexible tube attached to a tiny fiber-optic camera that is threaded up the nose and down the throat to permit inspection of the upper airway.

The procedure, Weil recalled, was traumatic for Vivienne and her parents. The little girl, terrified by what was happening, began screaming and had to be held down by several nurses so the doctor could perform the test.

Its results were definitive - and explained the reason for Vivienne's prolonged voicelessness. She was suffering from a rare disease called recurrent respiratory papillomatosis, which is caused by two strains of the human papilloma virus (HPV), a sexually transmitted infection that can be acquired at or before birth. The disease is incurable; it can be treated by surgery to remove the tumors which temporarily restores the voice. The goal of treatment is to lengthen the interval between surgeries while preventing permanent damage to the delicate vocal cords.

A painful answer

HPV is ubiquitous; nearly all sexually active adults have been exposed to it. Most people clear the infection from their bodies without ever knowing they had it. But in some cases two strains, HPV 6 and 11, can cause genital warts: benign, sometimes cauliflower-shaped tumors known as papillomas. These warts can occur months or sometimes years after exposure.

In some cases, mothers with genital warts can pass the virus during childbirth, resulting in the development of papillomas in the child's respiratory tract, particularly the larynx. (Two other strains considered "high risk" - HPV 16 and 18 - can cause cervical cancer. HPV can also cause oral, anal and penile cancer.)

The Centers for Disease Control and Prevention estimates that 2 in every 100,000 children have RRP, which can be prevented by a vaccine called Gardasil. Federal health officials recommend administering the vaccine, first licensed in 2006, to children at 11 or 12 before they are sexually active.

The pediatric ENT told the Weils it was a good thing they hadn't waited longer to seek treatment. Vivienne's tumors had grown so large they were threatening her airway.

"I was speechless," recalled Weil, who at the time was pregnant with her second daughter. "I thought, 'I gave this to my baby.' I remember sitting in that little room and thinking, 'She'll have to deal with this forever.' "

Weil said that she had no idea she ever had genital warts or had been exposed to HPV. In the car on the way back to their Maryland home, she said, she wept as she scrolled through her phone, frantically trying to learn about the disease, terrified that her second child might contract it, too.

Shortly before Vivienne's first surgery in November 2013, Weil sought answers from her obstetrician. How, she asked, could HPV have been missed?

The doctor replied that Pap smears performed in 2009 and 2011 were normal. Health officials do not recommend that women under 30 - Weil was 25 when Vivienne was born - routinely receive an HPV test because the virus is so common.

"It is possible that you had the virus and then your immune system cleared it so your test was negative in Dec. 2011" - 10 months after Vivienne's birth, the doctor wrote.

Nor is it clear that a Caesarean delivery would have prevented the disease. Experts say that some cases appear to have been contracted in utero.

Because of her age, Weil was not included in the initial targeting efforts for the vaccine, which focused on preteen girls. ( Federal health officials recently approved the latest version of the vaccine, Gardasil 9, which protects against nine strains of HPV, for adults up to age 45.)

Permanently silent?

Vivienne's first surgery, performed under general anesthesia, involved debridement, a procedure that essentially shaves off the tumors.

Weil said she remembers walking into the recovery room with her husband to hear Vivienne "crying loudly. It was so amazing," she recalled. "For us it was the best sound in the world."

But as is almost always the case, Vivienne's voice faded to a whisper after a few months as the tumors grew back. For the next few years she underwent simultaneous debridement of both vocal cords every four to six months.

In March 2018 after her 11th operation, her voice did not return. No physical explanation could be found, and doctors suggested the cause might stem from vocal cord weakness or psychological factors. For the next six months, Vivienne underwent hypnosis and saw speech therapists to no avail.

In desperation Weil posted a video of her daughter on Instagram. She hoped that someone - possibly another parent - might have some advice.

Within days, a California woman whose daughter has the disease suggested trying a different treatment. Instead of debridement, she recommended finding a doctor who uses a potassium titanyl phosphate (KTP) laser. Some specialists believe that use of the laser is superior, because it removes more tumor while minimizing damage to the vocal cords.

"I did a lot of research," Weil said. She found Simon Best, an otolaryngologist and researcher at Johns Hopkins who studies the disease and is an expert in laser treatment.

Weil said she tried unsuccessfully to make an appointment with Best but was told that he is not a pediatric otolaryngologist and therefore doesn't treat children.

Undeterred, she searched a medical database, unearthed his email address and sent him a message describing her daughter's case.

Best agreed to see Vivienne and Weil's insurer approved the out-of-network visit.

'Happy, babbly little girl'

Best, an associate professor of otolaryngology, estimates that in his 13-year career he has treated about 100 people, mostly adults, who have RRP. (An adult specialist, he treats patients of all ages with the disease.) Some developed the disease as children. In others, it arose in their 30s and 40s, a decade or so after HPV exposure.

"It has a horrible propensity to just keep coming back," Best said. One of his patients had endured 300 operations by the time he was 20. "You can imagine what that does to voice quality."

Best treats only one vocal cord at a time to prevent webbing, which occurs when the vocal cords grow together and can harm the voice.

"I was pleasantly surprised that there wasn't a huge amount of scarring," said Best of Vivienne, whom he first saw in September 2018.

The first laser surgery on the second grader's right vocal cord occurred in November 2018; her voice returned, but remained raspy. A second operation on the left vocal cord in January 2019 has had excellent results. A few days ago Vivienne underwent a successful repeat procedure on her right side.

"This is the best she has ever sounded," said her mother, adding that even the noise of her daughters' squabbling delights her.

In the past few months, she said, Vivienne has blossomed, eagerly making new friends and becoming a "happy, babbly little girl."

"She says that having a voice is even better than she thought it would be," Weil said. A year ago, she had told her mother that several classmates had excluded her from their game of "cheerleader."

Best recommends that a voice problem that lasts longer than a month should prompt an examination by "someone who can visualize the larynx."

It's difficult to predict how many surgeries Vivienne might need, he said. It's unlikely to be just three because recurrence is the rule. "Everyone has a unique clinical course," Best added.

"The earlier RRP is detected, the better," Best noted, before the disease can do extensive damage. "It's often overlooked for fairly long periods of time - months or years. And it doesn't enter the realm of diagnostic consideration in children until there are fairly severe effects."

The otolaryngologist remains a strong proponent of the HPV vaccine, which can prevent the disease. Weil said she plans to immunize her daughters and to get the vaccine herself, which could protect her against other strains of HPV.

According to the CDC, only half of American adolescents have been fully immunized. By contrast, Australia, which has promoted free immunization in schools for more than a decade, has dramatically reduced cases of cervical cancer and genital warts.

"Even though RRP is a rare disease, just from a psychosocial point of view, you can imagine what effect this disease has on families," Best said. "The mothers of these children have a big burden to bear."

Submit your solved medical mystery to sandra.boodman@washpost.com. No unsolved cases, please. Read previous mysteries at wapo.st/medicalmysteries.

The loud crunching noise in her head was driving her crazy

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A toddler's dwindling voice was chalked up to acid reflux. Her problem was far more serious.

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"I had never heard of it," her mother said of the little girl's surprising diagnosis. "Most people haven't."

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Meet Leonardo, a lively 2-year-old, born with a both of his vocal cords fused, who recently discovered his voice for the first time!

Leonardo was a healthy newborn, who arrived at 40 weeks and one day via C-section. He remained healthy throughout his first 10 months of life, avoiding even the most common childhood ailments. Shortly before Leonardo's first birthday, his family took a trip to visit relatives in Cuba. However, when Leonardo began to experience throat pain, fever, and difficulty breathing only two days into the trip, his mother and father, Yisell and Leo, decided to return home to Miami to seek help.

The family brought Leonardo to the Emergency Department at Nicklaus Children's Hospital. He was then admitted to the Pediatric Intensive Care Unit for 10 days for steroid treatment to help with his breathing, followed by another week in one of the medical units. When he was able to go home, Leonardo was referred to specialists, including a pediatric hematologist and a pulmonologist, both of whom could not find a reason for his difficulty breathing. When Leonardo's problems persisted, the family took him to the Nicklaus Children's Miami Lakes Outpatient Center where he was referred to a pediatric otolaryngologist or ENT who specializes in upper airway disorders.

Immediately, the worried parents scheduled an appointment with Dr. Brian Ho, pediatric otolaryngologist at Nicklaus Children's Hospital who was able to determine that Leonardo was experiencing "stridor," a harsh vibrating noise caused by an obstruction of the windpipe or larynx. Dr. Ho noted that Leonardo's vocal cords were fused from birth, causing him difficulty breathing with any type of common cold and preventing the child from speaking. Fortunately, his condition was treatable and involved a surgery to separate his fused vocal cords into two healthy vocal cords. Leonardo needed to grow a bit before surgery, so he was monitored for several months until the team was able to successfully operate on him shortly after he turned two, to give him a new voice that his parents can enjoy and experience with him at all his future milestones.

Hearing my baby say 'mama' and 'papa' with his own voice for the first time after surgery was the most rewarding experience of them all," said Yisell. "We are thankful, blessed and fortunate to have this level of care and experience available for our son right here in our community."

Today, Leonardo is a cheerful and explorative child who loves the playground and all things outdoors! He continues to visit Nicklaus Children's Hospital for follow up care and hasn't experienced any complications since his surgery.

If you or someone you know is experiencing breathing issues with their child and wants to be evaluated that you think might need surgery, please reach out to the department of otolaryngology and ask for the airway team at Nicklaus Children's Hospital.

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Leonardo's vocal cords were fused from birth, causing him difficulty breathing with any type of common cold and preventing the child from speaking. Fortunately, his condition was treatable and involved a surgery to separate his fused vocal cords into two healthy vocal cords.

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The Pediatric Voice Program at Children's Hospital of Philadelphia helped Kayla strengthen her voice, and she's putting it to good use: promoting her own book.

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Dysphonia and reflux in children: A systematic review

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Pediatric Voice Therapy: How Many Sessions to Discharge?

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WHAT SI VOCIE THERAPY? -educational hadnout

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Quick Screen for Voice and
Supplementary Documents for
Identifying Pediatric Voice Disorders

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Pediatric  voice  disorder:  who  to  refer  and  how  to assess?  A  summary  of  recent  literature

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Perceptual Evaluation of Severe Pediatric Voice
Disorders: Rater Reliability Using the Consensus
Auditory Perceptual Evaluation of Voice

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Management of Complex Pediatric Voice Disorders

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Beyond Nodules—Diagnostic and Treatment Options inPediatric Voice Disorders