Family‐Involved Hybrid Voice Therapy for Pediatric Vocal Fold Nodules in School‐Aged Children: Clinical Outcomes and Socioeconomic Associations

ABSTRACT

Objective(s)

To evaluate the effectiveness of a family‐involved hybrid voice therapy program in children with vocal fold nodules using multidimensional voice outcomes (objective acoustic, auditory‐perceptual, and parent‐reported measures) and to examine whether family socioeconomic opportunity is associated with baseline burden or posttreatment outcomes.

Methods

This prospective single‐arm pre–post observational study included children with vocal fold nodules confirmed by fiberoptic or videolaryngoscopic examination. Participants completed a 12‐week hybrid voice therapy program consisting of 12 weekly sessions alternating face‐to‐face and synchronous online delivery (six in‐person, six online). Caregivers received structured vocal hygiene education and were trained to support standardized Vocal Function Exercises with daily home practice (5–10 min/day) monitored using an exercise diary. Pre‐ and posttreatment assessments included acoustic measures (jitter, shimmer, cepstral peak prominence smoothed [CPPs], maximum phonation time [MPT], noise‐to‐harmonics ratio [NHR]), auditory‐perceptual evaluation (CAPE‐V), and parent‐reported impact (pVHI‐10). Family socioeconomic opportunity was assessed using the 20‐item Family Socioeconomic Opportunity Questionnaire (FSOQ; score range 0–60).

Results

Thirty‐nine children completed the program (mean age, 8.36 years). Significant pre‐ to posttreatment improvements were observed across outcomes, including increased CPPs and MPT and decreased NHR, jitter, and shimmer. CAPE‐V scores decreased from 34.46 ± 10.12 to 7.64 ± 4.76 (p < 0.001), and parent‐reported pVHI‐10 scores decreased from 27.62 ± 4.45 to 6.54 ± 3.07 (p < 0.001). At baseline, FSOQ showed a strong positive correlation with pVHI‐10 (r = 0.700, p < 0.001), indicating that higher FSOQ scores were associated with higher parent‐reported voice handicap. Posttreatment, FSOQ was not significantly correlated with CAPE‐V or pVHI‐10.

Conclusion

A 12‐week family‐involved hybrid voice therapy program was associated with substantial improvements in acoustic, perceptual, and parent‐reported outcomes in children with vocal fold nodules. Family socioeconomic opportunity was associated with baseline subjective burden but not with posttreatment outcomes. Controlled studies with longer follow‐up are warranted.

Level of Evidence

Level 3.

1. Introduction

Pediatric vocal fold nodules are among the most common benign lesions of the vocal folds in children and are typically related to vocal overuse or misuse [1]. Other pediatric voice disorders include vocal fold polyps, vocal fold cysts, laryngomalacia, and vocal fold paralysis [2]. These conditions can negatively affect voice quality and communication, restrict social interaction, and lead to a meaningful reduction in quality of life [3]. Because vocal fold nodules arise largely from maladaptive vocal behaviors, early recognition and appropriate behavioral management are particularly important.

The primary goals in treating pediatric voice disorders are to preserve vocal health and to improve the underlying pathology. Accordingly, conservative approaches are generally recommended as first‐line therapy. Depending on the clinical scenario, resonance voice therapy, intensive voice therapy programs, vocal hygiene education, and other traditional voice therapy techniques may be used [4, 5, 6]. However, in high‐volume clinical settings it is not always feasible to maintain continuity of frequent in‐person sessions or to support long‐term maintenance of gains. Hybrid care models that combine in‐person therapy with online sessions may help address these practical limitations.

Family‐involved voice therapy approaches aim to teach children to use their voice with appropriate technique, reduce phonotraumatic loading on the vocal folds, and support lesion regression [7]. For conditions that are closely linked to vocal misuse, such as vocal fold nodules, structured caregiver involvement may reduce the need for surgical intervention and improve long‐term outcomes [7].

Response to voice therapy is influenced by both individual and contextual factors. Family structure, social environment, and economic conditions may shape access to care, adherence, and clinical outcomes [2, 8]. Socioeconomic circumstances may be relevant in pediatric voice disorders and may contribute to differences in the distribution of diagnoses [9]. Nonetheless, studies examining the role of socioeconomic factors in treatment outcomes for pediatric voice disorders remain limited, and no single gold‐standard follow‐up measure has been established across the wide range of objective and subjective voice outcomes used in the literature.

Despite growing use of hybrid service delivery in pediatric voice therapy, evidence remains limited regarding (i) treatment‐related changes across objective and subjective voice domains and (ii) whether family socioeconomic opportunity relates to baseline severity or treatment response. Therefore, the primary aim of this study was to evaluate pre–post changes in objective acoustic parameters, auditory‐perceptual severity, and parent‐reported voice impact following a 12‐week family‐involved hybrid voice therapy program in children with vocal fold nodules. The secondary aim was to assess Family Socioeconomic Opportunity Questionnaire (FSOQ) and investigate its relationship with baseline voice‐related burden and posttreatment outcomes.

2. Materials and Methods

The study was initiated after approval from the local ethics committee (TABED 2‐24‐587). Between 2020 and 2024, 50 children aged 6–18 years who presented to the Otolaryngology Department of Ankara Bilkent City Hospital with dysphonia and were diagnosed with vocal fold nodules on flexible fiberoptic endoscopy and/or videolaryngoscopy (VLS) were enrolled. Children who did not complete the therapy program and therefore did not undergo posttreatment voice analyses were excluded; analyses were performed on the 39 participants who completed the intervention. Informed consent was obtained from all parents/legal guardians prior to participation.

2.1. FSOQ

To evaluate families' opportunities to access and participate in voice therapy, we developed a FSOQ based on the Child Opportunity Index (COI) [10] (Figure 1). The 20‐item questionnaire is organized under three domains (educational opportunities; health and environment; social and economic conditions). Each item is scored from 0 (lowest opportunity) to 3 (highest opportunity). The total score ranges from 0 to 60, with higher scores indicating greater socioeconomic opportunity.

FIGURE 1.

Family Socioeconomic Opportunity Questionnaire.

The FSOQ was developed based on COI domains and was pilot‐tested for clarity and feasibility prior to study implementation.

2.2. Acoustic, Auditory‐Perceptual, and Patient‐Reported Assessments

Acoustic analyses were performed using voice recordings obtained at the first session and after completion of the program. Recordings were collected in a controlled voice laboratory with ambient noise < 40 dB and minimized reverberation. Participants were positioned approximately 5 cm from the microphone (Sony ECM‐221; Sony Corporation, Tokyo, Japan) at an angle of ~45°.

For each recording, 3‐s segments were analyzed and averaged. Acoustic analysis was performed using a customized Praat workflow (www.praat.org; version 4.4.13, Amsterdam, The Netherlands). Objective measures included jitter and shimmer (reflecting fundamental frequency and amplitude perturbation), cepstral peak prominence smoothed (CPPs), maximum phonation time (MPT), and noise‐to‐harmonics ratio (NHR).

Auditory‐perceptual voice evaluation was performed using the Consensus Auditory‐Perceptual Evaluation of Voice (CAPE‐V). Parent‐reported voice‐related impact was assessed using the Pediatric Voice Handicap Index short form (pVHI‐10). All recordings were anonymized and scored by two independent evaluators.

2.3. Treatment Protocol

During the initial session, children and caregivers received visual, structured education about vocal fold anatomy, mechanisms of nodule formation, vocal hygiene, and strategies to prevent maladaptive vocal behaviors. The session emphasized optimal posture (relaxed jaw; upright head position; relaxed shoulders, back, and abdominal muscles; and slightly flexed knees), relaxation techniques, and diaphragmatic breathing to increase bodily awareness. Potential triggers for phonotraumatic behaviors in daily life (school, choir activities, sports, etc.) were identified using homework and tracking forms, and individualized solutions were discussed.

Participants underwent a 12‐week hybrid voice therapy program with their caregiver present. Sessions were held weekly and alternated between in‐person and synchronous live online delivery (Week 1 in‐person, Week 2 online), resulting in six in‐person and six online sessions per participant. All sessions were delivered by an experienced voice therapist/investigator.

Vocal Function Exercises (VFE) [11, 12] were standardized according to the principle of easy phonation. The program targeted maintenance of appropriate posture, breath–phonation coordination, and minimal laryngeal effort. Real‐time corrective feedback was provided when throat squeezing or hyperfunctional patterns emerged. Caregivers were trained at each session to guide the child during home practice, recognize incorrect technique, and support regular practice.

The VFE protocol consisted of four core tasks:

• Warm‐up: Sustained comfortable phonation of a vowel (e.g., /i/ or /u/) with an easy onset and without pushing.

• Ascending pitch glide (glissando): Gentle upward glide within the child's comfortable range.

• Descending pitch glide (glissando): Gentle downward glide within the child's comfortable range.

• Sustained/steady phonation: Stable, easy phonation at selected pitches within the comfortable range.

Age‐appropriate adaptations (e.g., shorter sustained duration or fewer repetitions) were permitted to maintain correct technique; however, the overarching target across all exercises was relaxed, stable voice production without strain. Families were instructed to complete daily home practice (approximately 5–10 min/day), tracked using a caregiver‐maintained exercise diary. Additional reinforcement and technique correction were provided if incorrect technique or adherence barriers were identified.

For safety, families were advised to temporarily pause home practice in the presence of throat pain, marked voice worsening, signs of excessive effort, or acute upper respiratory infection, and to review technique at the subsequent session. Adherence was monitored via the exercise diary, and the number of completed practice days relative to the planned schedule was recorded as a process variable.

2.4. Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows (version 21.0; IBM Corp., Armonk, NY, USA). The distribution of continuous variables was assessed using the Kolmogorov–Smirnov test. Continuous data were summarized as mean ± SD (or median [minimum–maximum], where appropriate), and categorical data as number (percentage). Pre‐ and posttreatment outcomes were compared using paired‐samples t‐tests. Associations between family socioeconomic opportunity (FSOQ) and voice‐related outcomes (CAPE‐V and pVHI‐10), as well as objective acoustic parameters, were evaluated using Pearson's correlation coefficients. Multivariable analyses (general linear models) were used to examine the effects of sex and age group on the evaluated voice parameters. All tests were two‐sided, and p < 0.05 was considered statistically significant.

3. Results

A total of 39 children completed the program and were included in the analyses. 18 were girls (46.15%) and 21 were boys (53.85%). Mean age was 8.36 ± 2.19 years (range 6–12 years). Across all objective acoustic, auditory‐perceptual, and patient‐reported measures, pre‐ to posttreatment changes were statistically significant.

3.1. Objective Acoustic Outcomes

Objective acoustic measures improved significantly following the intervention (Table 1). CPPs increased from 8.68 ± 0.44 to 9.79 ± 0.44 dB (p < 0.001), and MPT increased from 12.74 ± 1.19 to 18.85 ± 1.31 s (p < 0.001). NHR decreased from 0.25 ± 0.12 to 0.06 ± 0.06 (p < 0.001). Jitter and shimmer showed small but statistically significant reductions (p = 0.02 and p = 0.021, respectively).

TABLE 1.

Changes in objective acoustic voice parameters before and after treatment.

Parameter	Pretreatment (mean ± SD)	Posttreatment (mean ± SD)	p
Jitter (%)	1.38 ± 0.62	1.36 ± 0.69	0.02
Shimmer (%)	3.12 ± 2.87	2.93 ± 3.00	0.021
CPPs (dB)	8.68 ± 0.44	9.79 ± 0.44	< 0.001
MPT (s)	12.74 ± 1.19	18.85 ± 1.31	< 0.001
NHR	0.25 ± 0.12	0.06 ± 0.06	< 0.001

Abbreviations: CPPs = cepstral peak prominence smoothed; MPT = maximum phonation time; NHR = noise‐to‐harmonics ratio; SD = standard deviation.

3.2. Auditory‐Perceptual and Patient‐Reported Outcomes

Pretreatment FSOQ scores ranged from 24 to 56 (mean 36.13 ± 9.41; median 32). CAPE‐V scores decreased from a pretreatment range of 20–58 (mean 34.46 ± 10.12; median 30) to a posttreatment range of 0–22 (mean 7.64 ± 4.76; median 6), representing a highly significant improvement (paired t‐test: t(38) = 19.98, p < 0.001) (Table 2). pVHI‐10 scores decreased from a pretreatment range of 20–41 (mean 27.62 ± 4.45; median 26) to a posttreatment range of 2–12 (mean 6.54 ± 3.07; median 6) (t(38) = 22.64, p < 0.001) (Table 3).

TABLE 2.

Descriptive statistics for FSOQ, CAPE‐V, and pVHI‐10 scores before and after treatment.

Parameter	Min	Max	Mean ± SD	Median
FSOQ total score	24	56	36.13 ± 9.41	32
CAPE‐V (pretreatment)	20	58	34.46 ± 10.12	30
CAPE‐V (posttreatment)	0	22	7.64 ± 4.76	6
pVHI‐10 (pretreatment)	20	41	27.62 ± 4.45	26
pVHI‐10 (posttreatment)	2	12	6.54 ± 3.07	6

Abbreviations: CAPE‐V = Consensus Auditory‐Perceptual Evaluation of Voice; FSOQ = Family Socioeconomic Opportunity Questionnaire; pVHI‐10 = Pediatric Voice Handicap Index‐10; SD = standard deviation.

TABLE 3.

Changes in auditory‐perceptual (CAPE‐V) and parent‐reported (pVHI‐10) outcomes before and after treatment.

Parameter	Pretreatment (mean ± SD)	Posttreatment (mean ± SD)	p
CAPE‐V	34.46 ± 10.12	7.64 ± 4.76	< 0.001
pVHI‐10	27.62 ± 4.45	6.54 ± 3.07	< 0.001

Abbreviations: CAPE‐V = Consensus Auditory‐Perceptual Evaluation of Voice; pVHI‐10 = Pediatric Voice Handicap Index‐10; SD = standard deviation.

3.3. Associations Between Objective and Subjective Measures

Pretreatment CAPE‐V scores showed significant associations with shimmer and MPT, whereas no significant associations were observed after treatment. Similarly, pretreatment pVHI‐10 was significantly associated with NHR, but the association did not persist posttreatment (Table 4).

TABLE 4.

Associations between objective acoustic parameters and subjective voice measures.

Measure pair	Pretreatment, p	Posttreatment, p
CAPE‐V vs. shimmer	0.013	0.069
CAPE‐V vs. MPT	0.012	0.271
pVHI‐10 vs. NHR	0.028	0.061

Abbreviations: CAPE‐V = Consensus Auditory‐Perceptual Evaluation of Voice; MPT = maximum phonation time; NHR = noise‐to‐harmonics ratio; pVHI‐10; Pediatric Voice Handicap Index‐10.

4. Discussion

In this study, we evaluated the effects of a structured, family‐involved hybrid (in‐person + online) intensive voice therapy program on objective acoustic measures, auditory‐perceptual ratings, and parent‐reported voice‐related burden in children with vocal fold nodules. We observed statistically and clinically meaningful improvements across multiple domains, including MPT, jitter, shimmer, NHR, and CPPs, as well as marked reductions in CAPE‐V and pVHI‐10 scores. This multidimensional response pattern is consistent with prior reports supporting the effectiveness of behavioral voice therapy for pediatric vocal fold nodules [13, 14, 15]. Our work adds to the literature by systematically structuring caregiver involvement, implementing a hybrid delivery model, and incorporating socioeconomic opportunity into the analysis.

Systematic reviews have suggested that both direct and indirect voice therapy approaches can improve parameters such as CAPE‐V, jitter, shimmer, and NHR in pediatric vocal fold nodules but also highlight the limited number of well‐designed studies with long‐term follow‐up [16, 17, 18]. In busy clinical environments, clinicians often report insufficient time to counsel families and limited capacity to monitor home practice, which can undermine adherence and sustainability [19]. The alternating in‐person and synchronous online format used in our program increased opportunities for caregiver contact and facilitated structured monitoring of home exercises. Our findings suggest that meaningful therapeutic gains can be achieved even under high‐workload conditions when guidance and follow‐up are intentionally built into the model.

Behavioral voice therapy remains the recommended first‐line treatment for pediatric vocal fold nodules [14, 20, 21]. Resonant voice therapy, caregiver‐involved intensive programs, and telepractice‐based approaches have become increasingly common [5, 6, 22]. Although comparative studies have not consistently demonstrated superiority of a single technique, caregiver involvement and regular home practice are repeatedly emphasized as key determinants of success [23]. Although evidence on VFE in pediatric populations is limited [12], our results suggest that VFE‐based programs can be implemented effectively and safely in children when appropriately adapted and monitored.

Previous studies have indicated that many objective and subjective parameters can be used in pediatric vocal cord nodules [24]. From an outcome‐measurement perspective, the pronounced decrease in CAPE‐V scores alongside increases in MPT and CPPs indicates clinically meaningful improvements in phonatory efficiency and voice quality [17, 25]. Decreases in jitter, shimmer, and NHR further support improved phonatory stability, consistent with previous studies [15, 18, 26]. CPP has been proposed as a sensitive marker of therapy response, and our findings align with this view.

Marked reductions in pVHI‐10 scores indicate that the intervention substantially reduced perceived voice‐related burden for children and families. Both CAPE‐V and pVHI‐10 appear to be responsive and complementary outcome measures in pediatric dysphonia [27, 28]. Notably, we observed limited and inconsistent relationships between objective acoustic measures and subjective outcomes, underscoring the importance of a multidimensional assessment strategy in pediatric voice disorder.

A key feature of this study is the structured assessment of socioeconomic opportunity using the FSOQ and its relationship to voice outcomes. In our scoring, higher FSOQ reflects greater socioeconomic opportunity. We observed a strong positive association between FSOQ and the parent‐reported pVHI‐10, suggesting that higher opportunity co‐occurred with higher perceived voice handicap at baseline. This exploratory finding may reflect differences in symptom awareness, reporting behavior, or expectations, and therefore causal inferences should be avoided. Notably, FSOQ was not associated with clinician‐rated CAPE‐V, and after the intervention socioeconomic opportunity was not significantly related to either pVHI‐10 or CAPE‐V. These findings suggest that the observed baseline association was limited and should be interpreted cautiously. Despite being newly developed, the FSOQ was constructed based on the COI [29], which helped ensure coverage of clinically meaningful socioeconomic opportunity domains. Future work should focus on external validation and reliability testing to strengthen its use as a standardized measure.

Overall, our findings support family‐centered hybrid intensive voice therapy as a strong first‐line, non‐surgical intervention for pediatric vocal fold nodules, with large improvements in both objective and subjective outcomes. Future multicenter randomized controlled studies with longer follow‐up are needed to confirm the durability of gains and to identify robust predictors of treatment response.

This study has several limitations. First, the absence of a randomized control group limits causal inference regarding the extent to which observed improvements can be attributed solely to the intervention. The relatively small sample size and single‐center design may also limit generalizability across different clinical and sociocultural settings.

The FSOQ is a newly developed measure derived from existing indices; therefore, further validation in larger and diverse populations is required to establish its psychometric properties, including validity, reliability, and potential cut‐off points. In addition, caregiver‐reported measures such as the FSOQ and pVHI‐10 are inherently subjective and may be affected by responder bias.

Finally, the lack of long‐term follow‐up prevents conclusions about the durability of improvement, adherence over time, and recurrence rates. Future multicenter randomized controlled trials with extended follow‐up are needed to evaluate long‐term outcomes and to further clarify the role of socioeconomic measures in pediatric voice therapy.

5. Conclusion

A family‐involved hybrid voice therapy program yielded substantial improvements in acoustic, auditory‐perceptual, and parent‐reported voice outcomes in children with vocal fold nodules. While socioeconomic opportunity was associated with baseline subjective burden of dysphonia, it did not determine treatment response, suggesting that a structured and accessible therapy model may attenuate initial socioeconomic disparities. Further controlled, multicenter studies with longer follow‐up are needed to confirm durability of gains and to identify predictors of response.

Funding

The authors have nothing to report.

Ethics Statement

The study protocol was approved by the Institutional Ethics Committee of Ankara City Hospital (TABED 2‐24‐587) and it adhered to the principles of the Helsinki Declaration.

Consent

All participants provided written informed consent before participation in the study. All patients have agreed to and signed informed consent.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.