Technology

Voice production begins with the phonatory activity of the larynx when air from the lungs causing subglottal air pressure pushes against the closing vocal cords and forces them open (Cummings, 2008). This pushed column of air causes vibrations in the folds of the vocal cords (What is voice, NIDCD). When the subglottal pressure decreases, the cords will close. The extent to which the folds vibrate determines whether a whisper or normal speech or a shout will be produced. The vibratory quality of the voice is attributed to the passage of air through the oral, nasal and pharyngeal chambers. A deep voice becomes evident when the vocal cords are shortened and relaxed. A high pitched voice occurs when the cords are lengthened and tensed up. Defects in any part of the resonator can affect the voice production (Cummings, 2008). The brain pulls the trigger for the series of events which result in the production of voice just as in any body function. The vocal cords which lie in the larynx are two opposing bands of smooth muscle. The larynx is between the base of the tongue and top of the windpipe or trachea.
Voice is strictly personal and unique like the fingerprint. Ones personality or mood or health may be defined by voice. Statistics tell us that 7.5 million people in the United States have voice problems. Pre-school children between 2 years and 6 years have voice disorders in 3.9.  Dysphonia is seen in 6  of children (Cummings, 2008). Chronic voice disorders are found in 29.9. The current prevalence rate of voice disorder is 6.6. They could be those of pitch or loudness or quality. Pitch indicates how high or low a sound is and is based on the frequency of the sound waves. The loudness is the heard volume or amplitude of the sound. The quality of the voice constitutes the distinctive attributes (What is voice, NIDCD). The voice apparatus itself may not work this may occur when the nerves supplying the cords are injured due to viral infection, accident, surgery or cancer. The head, neck, chest and abdomen all participate in the speech production. Coordinated muscular actions in these areas produce speech. Years of practice alters the speech. A child learns how to produce sounds. Stuttering is one speech disorder which is found all over the world (What is voice, NIDCD). More than 15 million people stutter. Language is the communication through signs, sounds, gestures or marks as in some populations. More than 6 million people have language impairment in the United States causing effective communication to become a barrier.
Description of the disorder
Aetiology
    The commonest cause of hoarseness in an eight year old girl is inflammation and the two primary causes of inflammation are a viral infection or a laryngeopharyngeal reflux (Disorders of vocal use and misuse, NIDCD). Upper respiratory infections can also result in hoarseness due to any reflux of gastric contents. Hoarseness in children lasts a long time because nobody would have noticed it. 
    Vocal abuse is any behavior or occurrence that strains or injures the  HYPERLINK javascriptopenglossarywindow(160) o Link to definition vocal folds or  HYPERLINK javascriptopenglossarywindow(159) o Link to definition vocal cords (What is voice, NIDCD). Excessive talking or coughing or clearing the throat could cause a voice disorder. Inhalation of irritants or smoking or screaming could also lead to a voice problem. Vocal misuse is when improper usage occurs caused by speaking loudly or at an abnormal high or low pitch. The commonest and most preventable of hoarseness is due to vocal abuse and misuse. Anyone who uses their voice loudly like teachers, cheerleaders and singers can have vocal abuse.
    Risk factors are higher in females, age between  40 and 59 years, voice use patterns and demands, oesophageal reflux, chemical exposures and sinus infections (Cummings, 2008). Alcohol and tobacco were not risk factors. The incidence in teachers was slightly increased. Structural abnormalities of the larynx, neurological disorders, traumatic injuries to the larynx, infections, endocrine disorders, surgical and medical interventions, vocal abuse and misuse and gastro-oesophageal reflux. Benign lesions of larynx are a common cause of dysphonia. Viral
papillomas, laryngeal mucous gland retention cysts,  epidermoid cysts and vocal process granulomas.
Vocal nodules that occur because of vocal misuse and abuse can cause dysphonia (Williams and Carding, 2005 cited in Cummings, 2008). These are the commonest causes of voice disorders in schoolchildren. The nodules are very small swellings found at the margins of the vocal cords usually at the junction of the anterior and middle third of the vocal fold.  This is the area of maximal mechanical stress in voice abuse. Oedema or haemorrhage occurs from the mucosal layer due to persistent trauma (Sapienza, 2004 cited in Cummings, 2008). Malignant growths are less common. 
Nature of disorder
    The disorders of vocal abuse and misuse are usually laryngitis, vocal nodules, vocal polyps and contact ulcers (Disorders of vocal use and misuse, NIDCD). They are termed hyperfunctional voice disorders by health professionals. An inflammation of the vocal cords can be caused for many reasons and it is called laryngitis. Excessive use of the voice, bacterial and viral infections are the commoner reasons. Inhaled chemicals or gastro-oesophageal reflux can produce similar features. The voice will sound hoarse or raspy or breathy
.     Benign growths can be found on the vocal cords causing a common voice disorder associated with vocal abuse. Professional singers have this problem. Callous in nature, they
occur bilaterally, one on each cord. The nodules are at a specific region which has maximum stress with the closing of the cords with each stroke of voice production (Disorders of vocal use and misuse, NIDCD). Repeated pressure on the same area causes the nodules to form just like the callous formation on the feet. A hoarse, low-pitched and breathy voice will be produced.
    Vocal polyps which resemble blisters and are softer than nodules can be formed on any one fold. They are also termed Reinkes  oedema or degeneration of the polypoid type. Cigarette smoking of long term duration or thyroid deficiency can cause this (Disorders of vocal use and misuse, NIDCD). Gastro-oesophageal reflux or vocal misuse also can lead to this. The voice change is similar to that produced by the nodules.
    Contact ulcers can form on the fold when speakers forcibly bring their vocal cords together. Sores or wearing away of tissue near the cartilage causes these ulcers (Disorders of vocal use and misuse, NIDCD). The speakers feel tired easily and have pain in the throat.
Clinical Evaluation
    Intervention must follow an evaluation by a multidisciplinary team consisting of the otolaryngologist, speech and language therapist, gastroenterologist, psychologist, psychiatrist,
radiologist and occupational health worker in ideal circumstances (Cummings, 2008).
    a)    ENT- A hoarseness lasting more than two weeks needs a consultation with the ENT surgeon (otolaryngologist). Hoarseness is the feature which identifies all the problems of voice disorder. Physical symptoms could be bleeding, pain, dysphagia and coughing. Acoustic features are variable they include a habitual pitch, pitch range, loudness, vocal note quality, vocal flexibility and vocal stamina. A voice disorder can be too loud, too soft, too rough, having a high pitch or low. Secondary phonatory features may appear to compensate for the primary features adduction of the false vocal cords or an enhancement of the speaking fundamental frequency.
(Mathieson, 2001 cited in Cummings, 2008). Accompanying features that could be diagnostic of laryngeal cancer are dysphagia, earache, weight loss, blood stained saliva or neck swellings (Ng, 2000 cited in Cummings, 2008). Gastro-oesophageal reflux could be presenting as dyspepsia and heartburn. 56  of the participants had this reflux in a study by Ollivere et al (2006 cited in Cummimgs, 2008). Laryngel papillomatosis may be seen as cough , pneumonia, dysphagia or stridor or hoarseness in children.
    Taking the eight year old girl to the doctor may be a harrowing experience. However her crying will not disturb the doctors examination as he can see the movement of the vocal cords.
Physical examination of an eight year old girl may be a little difficult if she has breathiness. In that case, a radiograph of the chest and neck shows the area below the vocal folds,
the subglottis and the trachea. The specialist is able to visualize the vocal cords or folds. He can actually see the nodules or swellings or growths using a laryngoscope (Disorders of vocal use and misuse, NIDCD). He is able to make a provisional diagnosis with the laryngoscopy.  Fibreoptic laryngoscopy also can be done. Direct laryngoscopy may require an anaesthetic. Viewing of the cords during speech is possible. Microlaryngeal instruments may be used to decide the cause of the hoarseness. He may give his opinion and refer the patient to a speech language pathologist.
    b) Speech language pathologist- This health professional treats people with voice disorders. The pitch, loudness and quality of voice will be examined. Breathing techniques and
voicing style are assessed. A voice recording completes the examination. Techniques of therapy
are tested to see if improvement is possible (Disorders of vocal use and misuse, NIDCD). The GIRBAS score can be used for degree of voice abnormality, breathiness and roughness (Cummings, 2008). The GRB scale can be used to perform perceptual voice assessment in reflux laryngitis (Pribuisiene et al , 2006 cited in Cummings, 2008). Videostroboscopy can confirm diagnosis. A sound spectrogram can be taken to analyze the periodic wave form of the vocal signal  into sine waves with a differing frequency and amplitude (Mathieson, 2001 cited in Cummings, 2008). The Voice Range Profile gives a display of vocal intensity range against fundamental frequency. Acoustic analysis can also be done in computerised systems like the Speed lab Multidimensional Voice Program  or VisiSpeech or Kay Visipitch (Cummings, 2008).
Treatment

Interventions include surgery, drugs, radiotherapy and voice therapy. Surgery is recommended for vocal cord paralysis, benign tumors and malignant tumors. Treatment for the little girl would depend on the diagnosis.
Hoarseness of voice
    This is usually caused by irritation and swelling of the folds. The aim of treatment would be to remove the oedema. If the oedema is caused by the laryngopharyngeal reflux, this must be corrected. If the reason is vocal abuse, tips must be provided to prevent the abuse. If a post nasal drip in sinusitis has caused the problem, treatment must be given for it. Small growths like papilloma  or cyst may be surgically removed. Sometimes the cause of irritation may not be found. The treatment must then progress on the combined plan of the team.
Speech therapy is the main part of the therapy. It is especially useful for children who are aggressive about their voice. The initiation of the voice is taught to be comfortable. Comfortable yelling also is encouraged.
Gastro-oesophageal reflux
    This is treated medically or through behavior modification. Sleeping on a full stomach,
eating just before sleep, eating spicy foods are discouraged and the correct methods advised.
Carbonated beverages are to be avoided. Medications may be necessary at times.

Surgery
Structural problems like cysts, papillomas and nodules can be surgically treated.
Success of treatment
    Most of the children improve with treatment. The therapy selected should ensure a recovered good quality of the voice. The right combination of interventions must be administered after careful planning by the team.