Indirect vs direct voice therapy for children with vocal nodules: A randomized clinical trial

Christopher Hartnick, Catherine Ballif, Vanessa De Guzman, Robert Sataloff, Paolo Campisi, Joseph Kerschner, Adrianna Shembel, Domenic Reda, Helen Shi, Elinore Sheryka Zacny, Glenn Bunting

Research output: Contribution to journalArticlepeer-review

41 Scopus citations


IMPORTANCE: Benign vocal fold nodules affect 12%to 22%of the pediatric population, and 95%of otolaryngologists recommend voice therapy as treatment. However, no randomized clinical trials that we are aware of have shown its benefits. OBJECTIVE: To determine the impact of voice therapy in children with vocal fold nodules according to pretherapy and posttherapy scores on the Pediatric Voice-Related Quality of Life (PVRQOL) survey; secondary objectives included changes in phonatory parameters. DESIGN, SETTING, AND PARTICIPANTS: For this multicenter randomized clinical trial, 114 children ages 6 to 10 years with vocal fold nodules, PVRQOL scores less than 87.5, and dysphonia for longer than 12 weeks were recruited from outpatient voice and speech clinics. This age range was identified because these patients have not experienced pubertal changes of the larynx, tolerate stroboscopy, and cooperate with voice therapy. Participants were blinded to treatment arm. INTERVENTIONS: Participants received either indirect or direct therapy for 8 to 12 weeks. Indirect therapy focused on education and discussion of voice principles, while direct treatment used the stimulus, response, antecedent paradigm. MAIN OUTCOMES AND MEASURES: The primary outcome measurewas PVRQOL score change before and after treatment. Secondary phonatory measures were also compared. RESULTS: Overall, 114 children were recruited for study (mean [SD] age, 8 [1.4] years; 83 males [73%]); with 57 randomized to receive either indirect or direct therapy. Both direct and indirect therapy approaches showed significant differences in PVRQOL scores pretherapy to posttherapy. The mean increase in PVRQOL score for direct therapy was 19.2, and 14.7 for indirect therapy (difference, 4.5; 95.3%CI,-10.8 to 19.8). Of 44 participants in the direct therapy group, 27 (61%) achieved a clinically meaningful PVRQOL improvement, compared with 26 of 49 (53%) for indirect therapy (difference, 8%; 95%CI,-12 to 28). Post hoc stratification showed robust effects in the direct therapy group for older children (Cohen d = 0.50) and the latter two-thirds of participants (Cohen d = 0.46). Vocal fold nodules reduced in size in 31% (22 of 70) and completely resolved in 11% (8 of 70) of participants who consented to a second set of images after going through the recruitment process. CONCLUSIONS AND RELEVANCE: Both direct and indirect voice therapy improved voice-related quality of life in children with vocal fold nodules, although there was no significant difference between approaches. Future studiesmay focus upon which voice therapy approaches are effective in treating age-defined populations.

Original languageEnglish (US)
Pages (from-to)156-162
Number of pages7
JournalJAMA Otolaryngology - Head and Neck Surgery
Issue number2
StatePublished - Feb 2018
Externally publishedYes

ASJC Scopus subject areas

  • Surgery
  • Otorhinolaryngology


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