ARTICLE IN PRESS

Characteristics of Functional Dysphonia in Children

Jing Yang, and Wen Xu, Beijing, China

Abstract: Objective. Functional dysphonia refers to a voice disorder without organic laryngeal disease. In this
article, the clinical features and therapeutic strategies of functional dysphonia in children were investigated.
Method. Retrospective analysis of 595 cases of children with dysphonia 3 18 years of age, including 42 patients
diagnosed with functional dysphonia. The patients were distributed by age into four groups:3 6, 7 10, 11 14,
15 18 years. The clinical features, laryngeal signs, voice characteristics, pediatric voice handicap index, and ther-
apeutic effects were analyzed.
Result. In this study, 7.1% of the patients were struck with functional dysphonia. 7 (16.7%) patients aged
7 10 years, 16 (38.1%) aged 11 14 years, and 19 (45.3%) patients aged 15 18 years, and there were 23 males
and 19 females. Thirteen (31.0%) patients had no cause identified, while some were triggered by upper respiratory
tract infection (16 cases, 38.1%), voice overuse (9 cases, 21.4%), or other factors (4 cases, 9.5%). Thirty-four
(80.9%) patients had prominent hoarseness, with aphonia in 25 (73.5%) patients, and other 7 (16.7%) patients
(15-18 years) showed vocal breaks or vocal effort (4 patients), and high pitch or pitch instability (3 patients).
Some patients were accompanied by reduced mucosal waves, supraglottic compensations, and glottal insuffi-
ciency. Twelve patients received voice therapy, and their voice was improved after treatment.
Conclusion. In our study, functional dysphonia characterized 7.1% of the patients with voice disorders in chil-
dren. All patients were 7 18 years of age, particularly 11 18 years. The main triggers of the disorder were upper
respiratory tract infection, unknown and voice overuse. Other than apparent hoarseness, some 15 18 years
patients experienced vocal breaks, vocal effort, or abnormal pitch. Supraglottic compensations and glottal insuf-
ficiency were observed in more than half of the patients. Symptomatic voice therapy obtained significant effects.
Key Words: Functional dysphonia Dysphonia Voice disorders Children or pediatrics Voice therapy.

TAGEDH1INTRODUCTIONTAGEDN University, China, from January 2012 to April 2017. The

Pediatric voice disorders are relatively common and
vocal nodules are most common.1 3 It may be due to
dysplasia or vocal misuse or overuse. Functional dyspho-
nia (FD) refers to a voice disorder in the absence of
organic laryngeal disease. Functional dysphonia is rela-
tively common in adults.4 But it may be underestimated
in the pediatric population. In this article, the clinical
features, voice characteristics, and therapeutic strategies
of functional dysphonia in children were investigated.
TAGEDH1METHODSTAGEDN
Retrospective analysis of 595 cases of patients ranging in
age from 3 to 18 who received care at the Voice Medical
Center of the Beijing Tongren Hospital, Capital Medical
Accepted for publication July 27, 2018.
Funding
Beijing Municipal Administration of Hospital Clinical Medicine Development of
Special Funding Support (Code. XMLX201848) Programs of Beijing Health Founda-
tion of High level Technical Personnel (2014-2-004)
Conflict of interest: None.
Meeting information: The research was presented orally at the 12th International
Conference on Advances in Quantitative Laryngology, Voice and Speech Research
(AQL), Hong Kong, China, October 19, 2017
From the Department of Otolaryngology Head and Neck Surgery, Beijing Tongren
Hospital, Capital Medical University, Otolaryngology Head and Neck Surgery (Min-
istry of Education of China), Beijing, China.
Address correspondence and reprint requests to Wen Xu, Department of Otolaryn-
gology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical Univer-
sity, Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, 1
Dongjiaominxiang, Beijing 100730, China. E-mail: xuwendoc@126.com
Journal of Voice, Vol. &&, No. &&, pp. 1 4
0892-1997
© 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2018.07.027
medical history, age, sex, occupation, and other demo-
graphic characteristics of the patients were recorded. Sub-
jective perceptual assessments of voices were performed
using the grade, roughness, breathiness, asthenia, strain
scale. Additionally, the pediatric voice handicap index (p-
VHI) 30 was completed by the patients and their
parents.
Among 595 patients, 42 patients were found without
neurological and organic laryngeal disease when exam-
ined by strobolaryngoscopy. Therefore, these patients
were diagnosed with functional dysphonia. Patients diag-
nosed with functional dysphonia were then divided based
on age into four groups on average: 3 6, 7 10, 11 14,
and 15-18 years. The information on basic features,
causes, symptoms, voice characteristics, signs under stro-
bolaryngoscopy, treatments, and therapeutic effects from
42 cases of dysphonia patients was subjected to correla-
tion analysis.
SPSS Statistics version 17 (SPSS Inc., Chicago, IL) was
employed for statistical analyses of the ages, sex, clinical
features, and p-VHI 30 scores of the patients included. Data
with normal distribution are expressed in the format of X̄
§S. Data with abnormal distribution is expressed by
medians and quartile intervals. Comparisons of p-VHI
scores were performed using t test (a = 0.05).
TAGEDH1RESULTSTAGEDN
In this study, 7.1% of the patients were found with functional
dysphonia. There were 23 males and 19 females, with a male-
to-female ratio of 1.21:1. The age of the patients ranged from
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2 Journal of Voice, Vol. &&, No. &&, 2018

1 m) for all patients. Seventeen patients (40.5%) suffered

voice rest after dysphonia.
The manifestation of dysphonia was moderate to severe
hoarseness for 34 (80.9%) patients; among which 25 (73.5%)
patients presented with severe hoarseness or aphonia. While
7 (36.8%) patients experienced vocal breaks, vocal effort, or
high pitch or pitch instability among 15 18 years patients
(Table 2).

FIGURE 1. Age distribution of functional dysphonia in children.
7 to 18 years, with the average age of 14.0 (Figure 1). There
were 0 (0%) patients aged 3 6 years, 7 (16.7%) patients aged
7 10 years, 16 (38.1%) aged 11 14 years, and 19 (45.3%)
patients aged 15 18 years.
Clinical features
All patients had no previous history of voice diseases. The
main cause of dysphonia was upper respiratory tract infec-
tion for 16 (38.1%) patients, while 13 (31.0%) patients had
no cause identified. Other causes were vocal overuse for 9
(21.4%) patients and other factors induced by laryngeal
trauma, emotional stress, anger, or arguments for 4 (9.5%)
patients (Table 1). Disease course was 20 d-12 m (median
Strobolaryngoscopic signs
All patients were examined by strobolaryngoscopy, and
none had organic laryngeal lesions. Among the patients, 12
(27.8%) showed vocal fold edema, 6 (14.3%) showed vocal
fold hyperemia, and 27 (64.3%) showed microvascular dila-
tion. There were 31 (73.8%) cases with reduced mucosal
waves, 22 (52.4%) with incomplete closure of the glottis
(Table 3), and 21 (50%) with supraglottic compensations.
P-VHI 30 scale
The average score on the p-VHI-30 scale of the included
patients was 47.1 § 19.1; that of 7 10 years patients was
17.1 § 27.3, 11 14 years patients was 31.9 § 25.6 and that
of 15 18 years patients was 44.5 § 20.7.
Treatment and effects
Among the 42 patients, 25 patients (59.5%) received treat-
ment and 24 (96.0%) patients returned to their normal voice
after treatment. Twelve patients received voice therapy by
speech therapists (the average number of sessions attended

TABLE 1.
Causes of Functional Dysphonia in Children
Cause URTI Unknown Vocal overuse other factors Total
7-10 y 2 (28.6%) 0 5 (71.4%) 0 7
11-14 y 7 (43.7%) 4 (25.0%) 3 (18.8%) 2 (12.5%) 16
15-18 y 7 (36.8%) 9 (47.4%) 1 (5.3%) 2 (10.5%) 19
Total 16 (38.1%) 13 (31.0%) 9 (21.4%) 4 (9.5%) 42
URTI, upper respiratory tract infection.

TABLE 2.
Voice Characteristics in all 42 Patients
Group Grade 1 Grade 2 Grade 3 /aphonia Others Total
7-10 years 0 1 (14.3%) 6 (85.7%) 0 7
11-14 years 0 3 (18.7%) 13 (81.3%) 0 16
15-18 years 1 (5.3%) 5 (26.3%) 6 (31.6%) 7 (36.8%) 19
Total 1 (2.4%) 9 (21.4%) 25 (59.5%) 7 (16.7%) 42
Grade 1: slight hoarseness.
?Grade 2: moderate hoarseness.
?Grade 3: severe hoarseness.
?Others: include vocal breaks, vocal effort, or abnormally high pitch.
 ARTICLE IN PRESS
Jing Yang and Wen Xu Characteristics of Functional Dysphonia in Children
TABLE 3.
Abnormal Glottal Closure Showed in 22 Patients
Group Spindle Gap
7-10 y 2 (22.2%)
11-14 y 5 (55.6%)
15-18 y 2 (22.2%)
Total 9 3
Four of the patients showed complete closure when coughing.
was 1 2 times) and patients’ voice improved obviously
right after voice therapy, and returned to normal after
1 2 times treatment. Nine patients received orally adminis-
tered medication (such as antibiotics, traditional Chinese
medicines, and others), and 4 other patients received
psychotherapy.
TAGEDH1DISCUSSIONTAGEDN
Functional dysphonia refers to a voice disturbance in the
absence of structural or neurological laryngeal pathological
characteristics. In a preliminary study, we performed analy-
ses on 104 patients with functional dysphonia and found
that the onset tended to occur in two age groups, with the
11 20-year-old age being the most common, followed by
41 50-year-old age. Martins et al. studied 304 patients with
hoarseness, 3.28% of these patients had functional dyspho-
nia.2 However, further analyses of the clinical features were
not performed.
In this study, functional dysphonia comprised 7.1% of
the children with voice disorders. We also found that
functional dysphonia in children was more prevalent in
boys than in girls (1.21: 1). This result differs from that
found among adults, where functional dysphonia is
mostly seen in females. 5,6 There are no reports about age
distribution of functional dysphonia in children. In this
study, functional dysphonia in children showed a special
age distribution, which was found mainly among chil-
dren in age 11 18 (11 14, 38.1%; 15 18, 45.3%), the
average age was 14.0 years old, and not among
3 6 years children. It might be attributed to the rela-
tively stable laryngeal structure of children aged
3 6 years. Regarding children entering school age, voice
use were increasing, especially 15 18 years (puberty),
the larynx and other organs are undergoing the second
stages of rapid growth and development. These changes
are more prominent in boys than in girls. Moreover,
children in this group are not yet mature psychologi-
cally. These factors can all lead to a burst in the onset of
functional dysphonia.
Currently, functional dysphonia in adults is considered a
behavioral disorder and is correlated with stimuli such as
mental and psychological factors, vocal overuse, abnormal
phonation behavior, and imbalanced laryngeal muscle ten-
sion.7 In our research, upper respiratory tract infection was
3
Posterior Gap Incomplete Closure Total
0 2 (20%) 4
1 (33.3%) 3 (30%) 9
2 (66.7%) 5 (50%) 9
10 22
the most common inciting event (38.1%) for onset of func-
tional dysphonia in children, and less than 10% of the
patients had a history of psychological stimulation. The
cause was vocal overuse for 21.4% patients. What should be
pointed out is that 31.0% of the patients were found without
apparent causes. It's also obvious that the cause of different
age groups has its own characteristics in this study. 71.4%
patients of 7 10 years were caused by vocal overuse, and
43.7% patients of 11 14 years induced by upper respiratory
tract infection. What is even more noteworthy is that the
cause of functional dysphonia for most of the patients aged
15 18 years was more complex, 47.4% under unknown.
Therefore, it must be paid more attention on these children
without apparent causes while evaluation. Meanwhile,
cooperation from the patient's family and school staff mem-
bers is required for the diagnosis. In our study, 17 patients
(40.5%) had history of voice rest for days to weeks after dys-
phonia, and 12 (70.6%) of these patients with severe hoarse-
ness or aphonia. So we considered that improper voice rest
may aggravate dysphonia or cause secondary functional
dysphonia.
The symptoms of functional dysphonia in children were
more severe; 80.9% of the children showed prominent
hoarseness, and 73.5% of them presented aphonia. Our
study also showed that the symptoms of functional dyspho-
nia varied among 15 18 years patients. Other than promi-
nent hoarseness, 36.8% of the patients showed vocal breaks,
vocal effort, or high pitch or pitch instability. Such varia-
tions may be attributed to changes in phonatory organ
structures and changes in hormone levels during puberty.4
Meanwhile, the result of p-VHI 30 questionnaires8 also
demonstrated that the tendency of increasing scores with
age and some patients even temporarily dropped out of
school due to the disease. There is no significant specialty of
the age distribution on p-VHI scores. It may be due to the
poor understanding and expression ability of the younger
children. Therefore, we considered that it could be better
when the scale was filled out by parents and children
together.
Laryngoscopy, especially strobolaryngoscopy, is benefi-
cial in assessing the characteristics of dysphonia in chil-
dren.9,10 We found that more than half of the FD in
children exhibited reduced mucosal waves, supraglottic
compensations, and incomplete closure of the glottis. We
consider that strobolaryngoscopy helps to indicate an
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2018
abnormal phonation behavior or unbalanced laryngeal
muscle tension existing in children with FD.
Treatments for adults with functional dysphonia usu-
ally involve voice therapy and psychological therapy.11
There are a few studies on voice therapy for children with
functional dysphonia.12 14 In our study, 12 patients
received voice therapy. The training includes pressing
down on the larynx, cough-triggered phonation, and reso-
nance enhancement. All patients completely recover their
normal voice after voice therapy, mostly in the first ther-
apy. We also found that 7 14 years children are usually
difficult in focus attention and may have a poor under-
standing. Additionally, their cooperation in treatment
may be low due to fear or insecurity when encountering
strangers during treatment. Therefore, in our opinion,
voice therapy for FD in children does not have to be lim-
ited to the format for adults. Simple and short time symp-
tomatic voice therapy protocols should be implemented
for most FD in children, and cooperation from the parents
should be assured. For most children, respiratory support
training can be omitted during therapy. Regarding chil-
dren gradually grown up, psychological adjustment and
treatment should be supplied when necessary.
TAGEDH1CONCLUSIONTAGEDN
Functional dysphonia is not rare among voice disorders in
children and is more prevalent in boys. The age of onset
mainly occurred in 11 18 years while the disorder was not
seen among 3 6 years children. Psychological factors were
not significant for children, while factors such as upper
respiratory tract infection or excessive voice use were more
likely to be triggered; the cause of functional dysphonia was
unknown for some patients. And different age groups have
their own characteristics for causes. Other than apparent
hoarseness, some 15 18 years patients experienced vocal
breaks, vocal effort, and abnormal pitch. More than half of
the patients had accompanied signs of decreased mucosal
waves, supraglottic compensations, and incomplete closure
of the glottis. Symptomatic voice therapy obtained signifi-
cant therapeutic effects.
TAGEDH1SUPPLEMENTARY DATATAGEDN
Supplementary data related to this article can be found
online at doi:10.1016/j.jvoice.2018.07.027.
R
TAGEDH1 EFERENCESTAGEDN
1. Sama A, Carding PN, Price S, et al. The clinical features of functional
dysphonia. Laryngoscope. 2001;111:458–463.
2. Martins RH, Hidalgo CB, Fernandes de BM, et al. Dysphonia in chil-
dren. J Voice. 2012;26; 674.e17 20.
3. Possamai V, Hartley B. Voice disorders in children. Pediatr Clin North
Am. 2013;60:879–892.
4. Bhattacharyya N. The prevalence of pediatric voice and swallowing
problems in the United States. Laryngoscope. 2015;125:746–750.
5. Roy N, Merrill R, Gray SD, et al. Voice disorders in the general popu-
lation: prevalence, risk factors, and occupational impact. Laryngo-
scope. 2005;115:1988–1995.
6. Connor NP, Cohen SB, Theis SM, et al. Attitudes of children with dys-
phonia. J Voice. 2008;22:197–209.
7. Willingera U, Volkl-Kernstock S, Aschauer HN. Marked depression
and anxiety in patients with functional dysphonia. Psychiatry Res.
2005;134:85–91.
8. Lu D, Huang M, Li Z, et al. Adaptation and validation of Mandarin
Chinese version of the pediatric Voice handicap index (pVHI). Int J
Pediatr Otorhinolaryngol. 2018;104:19–24.
9. Jobran M, Ofer A, Doron S, et al. The accuracy of preoperative rigid
stroboscopy in the evaluation of voice disorders in children. J Voice.
2017;31;516 e1 e4.
10. Halawa WE, Munoz IV, Perez SS. Effectiveness of laryngostroboscopy
for monitoring the evolution of functional dysphonia after rehabilitator
treatment. Indian J Otolaryngol Head Neck Surg. 2013;65:322–326.
11. Bos-Clark M, Carding P. Effectiveness of voice therapy in functional
dysphonia: where are we now? Curr Opin Otolaryngol Head Neck
Surg. 2011;19:160 164.
12. Kollbrunner J, Seifert E. Functional hoarseness in children: short-term
play therapy with family dynamic counseling as therapy of choice.
J Voice. 2013;27:579–588.
13. Trani M, Ghidini A, Bergamini G, et al. Voice therapy in pediatric
functional dysphonia: a prospective study. Int J Pediatr Otorhinolar-
yngol. 2007;71:379–384.
€ Çiyiltepe M. Effects of voice therapy in school-age children.
14. Akin Ş O,
J Voice. 2013;27;787.e19 25.