2015 HSC Section 1 Book of Articles

Research Original Investigation

Progression of Pediatric Vocal Fold Nodules

and voice quality. Shah et al 9 did not find a significant corre- lation between VFN size and objective voice measures but noted that laryngoscopic findings correlated only with pitch reduction. In many other categories, both acoustic and per- ceptual, interesting although statistically insignificant dif- ferences were noted, with voice measures worsening as nodule size increased. That study, however, had limitations in that a validated instrument for the perceptual assessment of voice quality was not used. In a study by Nuss et al, 10 a significant correlation was found between nodule size and measures including roughness, strain, pitch, loudness, and overall severity. Additional study is needed to evaluate whether the same factors that influenced a greater rate of improvement in VFN size similarly result in improved acoustic measures, as well as parental and professional per- ception of voice quality. Conclusions The treatment plan for children with VFNs is an individual- ized one. In formulating a plan, onemust take into account the age of the patient, the patient’s motivation and ability to ad- here to therapy, and the degree of dysphonia and its impact on daily functioning. The present study provides informa- tion that may help to better guide treatment decisions and to better educate patients’ families in setting reasonable expec- tations and time course for improvement. Additional investi- gation is needed to look intowhether the findings in the pres- ent study persist regardless of prepubertal or postpubertal patient age and to determine whether the same factors that affect an increased rate of improvement in the size of the VFN also result in improved measures on acoustic and perceptual voice analyses.

which it was extrapolated to take approximately 1.5 years to observe a decrease in VFN size by 1 full grade. In contrast, in the prepubescent age group, very small increments of im- provement were observed over time. Possible explanations for the increased rate of improvement in the postpubertal age group include hormonal changes related to puberty, improve- ment in vocal hygiene with maturation, or improved adher- ence to treatment recommendations. In addition, the in- creased rate of growth of the vocal folds during adolescence may result in a change in the locationofmaximal shear stresses during phonation. In effect, this moving target of phonation- related vocal traumamay help decrease trauma to previously formed nodules, with a subsequent decrease in their size. As a next step, we plan to examine prepubertal and postpubertal subgroups, evaluating for whether the aforementioned treat- ment effects persist for both subgroups. De Bodt et al 4 examined the evolution of VFNs fromchild- hood into adolescence and found a significant sex difference. Overall, 21%of the study group reported voice complaints that persisted into adolescence; this included 37% of the girls and 8%of the boys. Objective datawere found to correlatewith the perceptual data, with VFNs persisting in 47% of girls and 7% of boys. In the present study, sex was not significantly corre- lated with the rate of change of VFN size. However, the me- dian age of our patient population was young (6 years); thus, a sexdifferencemayhave becomemore apparentwith anolder patient population. A shortcoming of the present study is that measures of voice analysis were not available for all patients, making it im- possible to analyze perceptual assessment of voice quality or acousticmeasures over time. It may be hypothesized that im- provement in laryngoscopic findings does not translate into improved voice quality. Prior studies are conflicting in terms ofwhether there is adirect correlationbetween the sizeof VFNs

Previous Presentation: This study was presented at the 2013 American Society of Pediatric Otolaryngology Spring Meeting; April 28, 2013; Arlington, Virginia. REFERENCES 1 . Wohl DL. Nonsurgical management of pediatric vocal fold nodules. Arch Otolaryngol Head Neck Surg . 2005;131(1):68-72. 2 . Shah RK, Feldman HA, Nuss RC. A grading scale for pediatric vocal fold nodules. Otolaryngol Head Neck Surg . 2007;136(2):193-197. 3 . Akif Kiliç M, Okur E, Yildirim I, Güzelsoy S. The prevalence of vocal fold nodules in school age children. Int J Pediatr Otorhinolaryngol . 2004;68(4):409-412. 4 . De Bodt MS, Ketelslagers K, Peeters T, et al. Evolution of vocal fold nodules from childhood to adolescence. J Voice . 2007;21(2):151-156. 5 . Roy N, Holt KI, Redmond S, Muntz H. Behavioral characteristics of children with vocal fold nodules. J Voice . 2007;21(2):157-168.

6 . Nuss RC, Ward J, Recko T, Huang L, Woodnorth GH. Validation of a pediatric vocal fold nodule rating scale based on digital video images. Ann Otol Rhinol Laryngol . 2012;121(1):1-6. 7 . Feldman HA. Families of lines: random effects in linear regression analysis. J Appl Physiol (1985) . 1988;64(4):1721-1732. 8 . Mori K. Vocal fold nodules in children: preferable therapy. Int J Pediatr Otorhinolaryngol . 1999;49(1)(suppl 1):S303-S306. 9 . Shah RK, Engel SH, Choi SS. Relationship between voice quality and vocal nodule size. Otolaryngol Head Neck Surg . 2008;139(5):723-726. 10 . Nuss RC, Ward J, Huang L, Volk M, Woodnorth GH. Correlation of vocal fold nodule size in children and perceptual assessment of voice quality. Ann Otol Rhinol Laryngol . 2010;119(10):651-655.

ARTICLE INFORMATION Submitted for Publication: June 18, 2013; final revision received October 29, 2013; accepted November 21, 2013. Published Online: January 16, 2014. doi:10.1001/jamaoto.2013.6378. Author Contributions: Drs Nardone and Nuss had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Nardone, Nuss. Acquisition of data: Nardone, Recko, Nuss. Analysis and interpretation of data: Nardone, Huang, Nuss. Drafting of the manuscript: Nardone. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Huang. Administrative, technical, or material support: Recko, Nuss. Study supervision: Nardone, Nuss. Conflict of Interest Disclosures: None reported.

JAMA Otolaryngology–Head & Neck Surgery March 2014 Volume 140, Number 3

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