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For children with voice nodules, both direct voice therapy -- which focuses more on voice simulation and practice -- and indirect voice therapy -- which focuses on education and discussion of voice principles -- improved quality of life scores, a small randomized trial found.

Both types of therapy improved voice-related quality of life scores for children ages 6 to 10 years with vocal fold nodules, relative to baseline, with no significant difference observed between the two, reported Christopher Hartnick, MD, of Massachusetts Eye and Ear in Boston, and colleagues.

Moreover, more than half of children in both therapy groups showed a clinically meaningful improvement in quality of life following therapy, the authors wrote in

They noted that more than 3 million children are referred to speech-language pathologists for voice therapy, adding that these voice disorders may have detrimental effects on children, including "underdeveloped communication skills and psychological abilities that are associated with poor self-esteem and self-consciousness," as well as ongoing treatment into adulthood if these issues are not resolved during childhood.

Hartnick and colleagues said nearly all otolaryngologists prescribe voice therapy for pediatric vocal fold nodules, but "no study that we are aware of has determined its benefits."

They set out to do this in this randomized trial comparing a direct treatment approach called "Adventures in Voice" with an indirect treatment approach called "My Voice Adventure." Participants had quality of life scores lower than 87.5 and dysphonia, or hoarse voice, for longer than 12 weeks. Quality of life was measured via scores on the .

Overall, 114 children were recruited from outpatient clinics, and 57 were randomized to receive either direct or indirect therapy for 8 to 12 weeks. Children averaged about 8 years old, and nearly three-quarters were boys -- reflective of the general clinical situation, the authors noted.

Mean increases in this quality of life survey score post-therapy compared to pre-therapy were 19.2 for direct therapy and 14.7 for indirect therapy, with 61% of the direct therapy group and 53% of the indirect therapy group achieving clinically meaningful improvements in their quality of life scores, the authors said.

Post-hoc analyses of changes in these quality of life scores found a "medium effect size" that favored direct therapy in children 8 and older (Cohen d =0.50), as well as the latter two-thirds of all participants (Cohen d=0.46). The authors said this suggested "a possible learning curve for the administration of the [direct] therapy."

Hartnick and colleagues emphasized that there was no control group in this study because "our data and safety monitoring board ... deemed it unethical."

That there were improvements with both forms of voice therapy may be due to "parent expectations that the time was worth the investment," the investigators indicated. "[I]t suggests that such improvement may be explained due to therapy in general."

Further studies should focus on which therapy approaches are the most appropriate for specific age groups, they said.