Predictive Role of Vocal Fold Development in Pediatric Voice Therapy Outcomes

Nassim Ahmadi, Rita Patel, Hamzeh Ghasemzadeh, Hamide Ghaemi, Bernhard Jakubaß, Dimitar Deliyski, Katherine Verdolini Abbott

Objective: Although voice therapy is the primary treatment for pediatric vocal fold nodules (VFNs), few children receive it, as children are often considered “too young” for therapy or assumed to outgrow the disorder. While kinematic studies report that shorter vocal folds and higher closing velocities contribute to phonotrauma, biological studies highlight the regenerative capacity of children’s vocal folds in recovering from phonotrauma. Understanding developmental factors that may influence therapy outcome is key to clinical decision-making. This study examines the developmental predictors of pediatric voice therapy outcomes and the influence of age and sex.

Methods: This longitudinal observational study enrolled 22 children (mean age 7.9 ± 1.7 years, range 4–11) with VFNs at Indiana University. Ten children completed baseline assessments and a full course of the Adventures in Voice therapy program, followed by post-therapy assessment. High-speed laryngeal videoendoscopy was performed before and after treatment. Pretreatment kinematic measures, including normalized average and peak closing velocity and speed quotient, were extracted. Velocity was normalized by vocal fold length and fundamental frequency and computed across three scanning lines (at the lesion site, 10% above, and 10% below the lesion). Three laryngologists rated nodule size pre- and post-treatment using a revised Nuss scale. The primary outcome was “percent change in lesion size” from baseline to after treatment. Multiple linear regressions tested each kinematic predictor separately, controlling for age and sex.

Results: Analysis revealed that several kinematic measures significantly predicted lesion-size reduction following therapy. Across models, higher normalized peak closing velocities at the lesion site, 10% above, and 10% below, were associated with larger post-treatment lesion-size reduction (βs = −0.64 to −0.80, p < .047). Similarly, higher normalized average closing velocities at the lesion site and 10% above predicted larger post-treatment lesion-size reduction (βs = −0.64 to −0.83, p .10). Age was a positive predictor only at the lesion site (β = 0.62 – 0.65; p < .009), indicating smaller reductions in older children, while sex was not significant across all models. Interrater reliability for nodule size ratings was excellent (ICC = 0.907, 95% CI = 0.822–0.955, p < .001; Cronbach’s α = 0.91).

Conclusions: Findings suggest that higher closing velocity and younger age are associated with better physical treatment outcomes, underscoring the importance of early intervention.