Pediatric Dysphonia: When to Refer.

The reported prevalence of voice disorders in the pediatric population varies widely between studies, ranging from 3.9% to 23%. Despite this, not all children with dysphonia are referred to a voice specialist for further evaluation. The objective of this study is to examine the relationship between dysphonia history, voice assessment, and laryngeal findings to help guide referrals of dysphonic children. A retrospective review was conducted of pediatric patients at a tertiary voice clinic between January 2014 and December 2017. Data including dates of presentation, demographics, co-morbidities, presenting symptoms, laryngeal exam findings, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores, and Pediatric Voice Handicap Index (pVHI) scores were collected and analyzed. Of 475 patients initially identified, 459 met inclusion criteria and were reviewed. In all, 272 (59.3%) were male and 187 (40.7%) were female. Mean age at first presentation was 8.6 years old (range: 2-18). Males were more likely to present at a younger age than females. CAPE-V data were available for 439 patients, and pVHI data were available for 109 patients. The mean CAPE-V Overall Severity score was 38.2. The mean total pVHI score was 25.4. Males had higher CAPE-V Overall Severity (40.0 vs. 35.4), Roughness (32.2 vs. 27.6), and Strain scores (37.2 vs. 32.4) than females. Patient pVHI scores did not differ by gender. In all, 283 patients self-reported a length of symptoms prior to evaluation. Children with a longer duration of symptoms prior to evaluation had higher CAPE-V Overall Severity scores. Diagnoses of vocal fold movement impairment and benign vocal fold lesions that were not nodules were associated with higher average CAPE-V Overall Severity scores. Overall, 310 patients (67.5%) were recommended intervention for their dysphonia. These patients had higher CAPE-V Overall Severity scores than those who were solely recommended observation (42.8 vs. 28.0). Males were more likely than females to present with dysphonia and presented with more severe perceptual dysphonia scores on average. The length of symptoms and certain diagnoses correlated with higher CAPE-V Scores. Referrals to a pediatric voice clinic should be considered in patients with a dysphonia history lasting greater than 3 months and in patients with more severe symptoms.

Utility of telemedicine in tracheostomy-dependent children.

Objectives: Telemedicine can improve access to pediatric otolaryngology care by decreasing travel time and cost, and lowering the risk of viral transmission during the SARS-CoV-2 (COVID-19) pandemic. This study aims to identify the clinical role and outcomes of telemedicine for tracheostomy-dependent children before and during the COVID-19 pandemic. Methods: Retrospective chart review of 42 tracheostomy-dependent pediatric patients who utilized telemedicine between October 2013 and April 2020 (pre-COVID-19), and 111 patients who utilized telemedicine between May 2020 and July 2021 (during COVID-19) at a tertiary free-standing children's hospital outpatient clinic. Results: The majority of pre-COVID-19 telecommunication solely addressed tracheostomy stomal concerns as compared with during COVID-19 (99% vs. 3%, p < .001), while telecommunication during COVID-19 was mainly used for routine follow-up as compared with pre-COVID-19 (99% vs. 0%, p < .001). Telemedicine visits during COVID-19 were significantly less likely to result in the need for in-person office visits as compared with those pre-COVID-19 (4% vs. 22%; p < .001). There was no significant difference in urgent emergency department (ED) evaluation following telemedicine pre- and during COVID-19 (16% vs. 11%). The most common reasons for ED presentation both pre- and during COVID-19 following telemedicine visit included respiratory distress, dislodged tracheostomy tube, and tracheostomy bleeding. Conclusion: The clinical role of telemedicine has evolved from problem-based evaluation to routine follow-up during the COVID-19 pandemic. Although telemedicine can decrease the need for in-person office evaluation of routine tracheostomy concerns, respiratory complications and tracheostomy bleeding still require urgent in-person ED evaluation. Level of evidence: Level 4.

Laryngeal pathologies in dysphonic children with Down Syndrome.

INTRODUCTION: Down syndrome is the most common chromosomal abnormality and is associated with a higher incidence of congenital heart defects, which often require surgery within the first year of life. Previous studies have found that children with Down syndrome are at higher risk for subglottic stenosis, vocal fold paralysis, and laryngomalacia. The goal of this study is to review children with Down syndrome presenting with dysphonia and to characterize their laryngeal pathologies. METHODS: A retrospective review was performed of patients with Down syndrome seen at a tertiary pediatric hospital's department of otolaryngology from Jan. 2007-Jul. 2021 for voice-related concerns. Inclusion criteria included age less than 18 years, diagnosis of Trisomy 21, and complaint of dysphonia. The data extracted included history of dysphonia, co-morbidities, demographic information, age at presentation, perceptual voice assessments, voice quality of life scores, acoustic data, laryngoscopic and/or videostroboscopic exams, and surgical procedures. RESULTS: Twenty-three total patients met the study criteria. Of these children, 13 (57%) were male and 10 (43%) were female. The mean age at first presentation was 4.08 years (range 12 days-16.3 years). Eleven of the 23 patients presented within the first 12 months of life. Sixteen patients were diagnosed with vocal fold immobility, 13 of which were left-sided unilateral immobility and the remaining 3 were bilateral immobility. 5 patients were diagnosed with vocal fold nodules. 12 children in the immobility group had a history of cardiothoracic surgery at our institution. Only 3 patients had Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) assessments, though all three showed overall dysphonia ratings of severely deviant, with roughness and strain scores being the most severe. DISCUSSION: The most common etiology of dysphonia in our Down syndrome patient population was vocal fold immobility and hypomobility, as opposed to vocal fold nodules (which is the most common in the general pediatric population). The higher likelihood of cardiac surgery in patients with Trisomy 21 may result in the increased incidence of vocal fold immobility. There should be a low threshold to refer dysphonic patients with Down syndrome for laryngoscopic evaluation, as treatment options may be available.

Telehealth for Treatment of Pediatric Dysphonia.

BACKGROUND: Vocal fold nodules are the most common etiology of chronic dysphonia in the pediatric population. Voice therapy is an effective first line of treatment, with increasing evidence supporting the use of telepractice in speech pathology. Despite this, there is limited data on its effectiveness in the pediatric population. The aim of this retrospective study was to investigate the feasibility and efficacy of telepractice in delivering voice therapy to children diagnosed with vocal fold nodules. METHODS: A retrospective review was conducted of patients treated with virtual voice therapy from April 2020 to June 2021. Patients were included if diagnosed with vocal fold nodules, 2-18 years of age, and completed therapy in a virtual format. Data includes demographics, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores and pediatric Voice Handicap Index (pVHI) scores. RESULTS: Twenty-three children were included, 17 (74%) male and six (26%) female (with an age range of 2.4-9.9 years at the start of therapy). Prior to treatment, the average CAPE-V Overall Severity score was 37.9 (SD 13.8); the average posttreatment score was 22.4 (SD 10.2). The average pVHI total score prior to treatment was 26.3 (SD 12.1), with an average posttreatment score of 20.2 (SD 11.7). Patients who underwent virtual voice therapy had improved posttreatment CAPE-V severity scores than those prior to treatment (average difference = -15.5 points; 95% CI: -8.3 to -22.7; P < 0.001). An increased number of therapy sessions was associated with both higher initial CAPE-V severity scores (r = 0.72; P < 0.01) and a greater decrease in posttreatment CAPE-V scores (r = -0.55; P < 0.01). CONCLUSION: Virtual voice therapy may be feasible and efficacious in treating dysphonic children diagnosed with vocal fold nodules. Significant improvements were found in perceptual CAPE-V scores in overall severity; positive changes were also seen in parental measures of quality of life. Delivery of voice therapy in a telehealth format may increase access of care and should be considered as a treatment option.