Page 27 - Portuguese Journal - SPORL - Vol 61. Nº1

Discussion Martins et al. described a higher percentage
Seventy-three children with an objective
diagnosis of chronic dysphonia on clinical
observation were evaluated between
September 2018 and December 2021 in the
first consultation at the voice clinic of the HDE.
The mean age of these children was 9.6 years;
65.8% of them were aged between six and 12
years and 72.6% were boys. These demographic
characteristics were as expected and similar to
those reported in other studies on dysphonic
children, which describe mean ages between
nine and 11 years with 64% of the children
1,4
aged between seven and 12 years , and 62% to
5
70.1% of the children being boys. 1,4,5
All diagnoses were benign, with the main one
being VC nodules (42.5%). VC nodules have
been reported in the literature as the main
cause of pediatric dysphonia and accounted
for 40% to 57.6% of cases in previous studies. 1,4,5
The second most frequent diagnosis was LPR
(12.3%). This condition is reportedly frequent
among children with dysphonia and is the
etiological diagnosis in 24% to 36% of cases.
4,9
A recent systematic review showed a strong
relationship between gastroesophageal or
laryngopharyngeal reflux and the development
of dysphonia in the pediatric population. 10
In the present study, a phonotraumatic
behavioral profile was detected in 57.5% of
cases, which is similar to that reported by other
authors (54.7%). Patients and carers should
5
be systematically asked about the presence
of phonotraumatic behaviors, which include
screaming or loud talking, excessive talking,
intense whispering, making abrupt glottic
attacks and sound effects (e.g., imitating
characters), and throat-clearing, because they
are present in most cases and are a key area of
therapeutic intervention. 11
The presence of inflammatory disease
which may be involved in the development
of dysphonia should also be systematically
investigated. In the present sample, nasal
4
symptoms were exhibited by 26% of patients
and LPR was detected in 20.5% of cases, and a
significant association between the symptoms
and a diagnosis of LPR was established.
of nasal symptoms (36.2%) and a lower
percentage of LPR symptoms (3.6%). Given
5
the subjectivity inherent to the description
of symptoms, some variation in the observed
percentages is to be expected, depending
not only on how the patients and their carers
perceive these complaints but also on how
the physicians investigate their presence.
Performing laryngoscopy to determine the
diagnosis in children with dysphonia is deemed
essential and feasible in most cases. The
12
larynx was visualized in 78.1% of children in the
present sample, using a flexible laryngoscope
in all cases (49.3% FOL and 28.8% DCL). A study
that compared the diagnostic accuracy of
rigid and flexible laryngoscopy, using direct
laryngoscopy as the gold standard, showed
the superiority of the former (64% vs 30%),
but only rigid laryngoscopy exams used
stroboscopic light and all flexible laryngoscopy
exams were performed with fiberoptic devices
coupled to a camera head and not with a
distal chip. Although rigid laryngoscopy
13
is described in the literature to yield high-
quality images, with greater magnification
and better lighting, and is feasible in 85% of
children aged seven years and more , it can
14
be difficult to execute because it depends
on an individual child’s ability to collaborate
and tolerate the exam. Additionally, this
population has a more marked pharyngeal
reflex and shorter phonation time. In our
15
experience, DCL provides high-quality images
and is well accepted by patients and carers,
thus allowing satisfactory management of
children with dysphonia; therefore, the use of
rigid laryngoscopy during consultation is not a
common practice in our center.
In the present study, after the exclusion
of demographic, behavioral, and clinical
differences between the children assessed
using either DCL or FOL, there was a trend
towards a reduced proportion of diagnosed
VC nodules and of laryngoscopy exams being
classified as normal, as well as an increase in
the proportion of LPR with the use of DCL,
although the described differences were not
Volume 61 . Nº1 . March 2023 27