CASE REPORT: Vocal acoustic characteristics of adenotonsillar hypertrophy and adenotonsillectomy in young child.

CASE REPORT: Vocal acoustic characteristics of adenotonsillar hypertrophy and adenotonsillectomy in young child. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report CASE REPORT: Vocal acoustic characteristics of adenotonsillar hypertrophy and adenotonsillectomy in young child. Yasuhiro Tanaka, Mayu Tanaka This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7173808/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2025 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Adenotonsillar hypertrophy, which is the cause of the majority of sleep disorders in children, can cause various problems. One of the symptoms is a voice disorder, but the details remain unclear. The reasons 1) excluded young children (3-6 y.o.), even though tonsillar hypertrophy affects from previous studies, 2) are on a wide range of participants ages, 3) fail to investigate the effects associated with vocal abuse or misuse, and 4) do not take into account the effects of postoperative sore throat (POST) associated with the surgery or tracheal intubation on voice quality, resulting in inconclusive results. This study aimed to perform a vocal acoustic analysis on the effects of adenotonsillar hypertrophy and adenotonsillectomy by eliminating these obstacles as much as possible. The results of this study will help to recognize the type of this symptoms-related voice disorders, and information based on acoustical objective indexes for medical doctors, patients, and their families. Case presentation: We collected the vocalizations of patient, he was a boy aged three years, for the 10 days before the surgery, and for five days at 1, 3, and 6 months postoperatively. Voices were recorded twice, once in the morning (AM) and once in the evening (PM), and used for acoustic analysis. Although this is a single case, no previous report has investigated the effects of adenoids on voice in such a long-term and detailed manner, and it’s a valuable report. Results: The parameters indicating voice pitch (fundamental frequency: Fo), glottic insufficiency (noise-to-harmonic ratio: NHR), and vocal fold stiffness (degree of subharmonic: DSH) improved after surgery. These results suggested that the tonsillar hypertrophy may contribute to the phonotrauma, and adenotonsillectomy seems to have positive effect not only on the improvement of obstructive sleep apnea (OSA) in child, but also on the development of voice. Voice Acoustic analysis Adenoids Obstructive sleep apnea Tonsillar hypertrophy Figures Figure 1 Figure 2 Figure 3 Introduction Pharyngeal and palatine tonsils become considerably enlarged in the early childhood. Their tonsillar hypertrophy is because it can cause respiratory disorders and obstructive sleep apnea (OSA)[1], which are linked with substantially affect child health status and quality of life (QoL)[1,2], such as underdevelopment of the thorax, heart failure[3,4], and poor concentrating during the day[5,6]. Furthermore, such tonsillar hypertrophy can trigger voice disturbance[7-9] because mouth-breathing can cause throat dryness and inflammation[10], and tonsillar secretions might cause induce mucosal inflammation of the vocal cords[11]. The location of these tonsils in the upper airway (vocal tract) are inferred that air exhaled for speech can generate air turbulence, thereby affecting the degree of glottal closure[8,12]. However, there is scant research on objective changes to acoustic parameters associated with adenotonsillar hypertrophy and adenotonsillectomy. Even though some data reveal significant results, the majority of studies; 1) excluded young children, even though tonsillar hypertrophy affects[10,13], 2) are on a wide range of participants ages[7,8,13], 3) fail to investigate the effects associated with vocal abuse or misuse[14,15], and 4) do not take into account the effects of postoperative sore throat (POST) associated with the surgery or tracheal intubation on voice quality[1,16,17], resulting in inconclusive results. We consider that the challenges associated with including child participants in such studies is assumed to be the reason why studies on the topic have not included young children in their analysis. This study aimed to perform a vocal acoustic analysis on the effects of adenotonsillar hypertrophy and adenotonsillectomy by eliminating these obstacles as much as possible. The valid objective data by acoustic analysis might be able to reduce that those patients and their parents have some concerns about the voice change of after surgery[13], and might help the medical doctors provide a meaningful statement. Methods Participant The participant was a boy aged 3 years and 2 months (height, 102.2 cm; weight, 17.1kg) who presented with the chief complaint of habitual snoring (Supplemental video 1) and apnea during sleep. Lateral x-ray showed hypertrophy of the pharyngeal and palatine tonsils (Figure 1) with a severity of 3 on the Friedman’s tonsil grading scale (Figure 2)[18]. Flexible laryngoscopy revealed no structural changes or inflammations such as vocal nodules and/or vocal cord polyp, and the patient did not have any subjective symptoms related to vocal function such as discomfort, abnormality, or behavioral abnormality during vocalizations. The Japanese version of Picture Vocabulary Test-revised[19] scaled score was 10, intelligence was evaluated as being at an average level, and the participant had never been noted as having developmental abnormalities in any baby health checkup. This study adhered to the Ethics Guidelines for Epidemiological Studies endorsed by the Japanese government and was approved by the Ethics Review Committee of Aichi Gakuin University (no.2020y). Informed consent was obtained from this participant and his mother. Assessment protocol Vocal function was assessed four times; that is, before the adenotonsillectomy (Base line, BL), and at 1 month (1M), 3 months (3M) and 6 months (6M) postoperatively. The BL assessment was made over 10 days in the 1-month period before the surgery, and the assessments at 1M, 3M, 6M were performed for 5 consecutive days. The assessments were always made during the week on a day when the participant went to nursery school. Assessments on these days were made twice, once in the morning (AM) and once in the afternoon (PM). The AM assessment was made at least 30 min after waking up, and the PM assessment was made by collecting speech samples before dinner and bath time. Voice samples The sustained vowel /a:/ was taken for the voice sample. The analysis of the sustained vowel followed the procedures of a previous study[20,21]: the mean of two vocalizations of the vowel /a:/ for 5 seconds in a comfortable, habitual pitch and loudness was used as the result. All voice samples were recorded in a sound-treated room and digitized in a voice recorder (ICD-SX813; SONY, Tokyo, Japan) at a sampling rate of 44.1 kHz and 16 bit quantization. A microphone (ECM-MS907; SONY, Tokyo, Japan) was appropriately positioned to maintain a constant mouth-to-microphone distance of 15 cm during speech recording, and the recorded speech samples subsequently used for acoustic analysis. Acoustic Analysis The Multi-Dimensional Voice Program (MDVP; Computerized Speech Lab, CSL; PENTAX Medical, Lincoln Park, NJ) was used to analyze the nine main parameters for the acoustic analysis of the sustained vowel: average fundamental frequency (Fo) and standard deviation of Fo (STD), pitch of voice; jitter percent (Jitt), frequency perturbation measurements; shimmer percent (Shim), amplitude perturbation measurements; noise-to-harmonic ratio (NHR), noise-related measurements; Fo-tremor and amplitude-tremor intensity index (FTRI and ATRI), tremor related measurements; degree of subharmonics (DSH), subharmonic component-related measurements; and degree of voiceless (DUV), voice irregularity-related measurements. The general criterion of the capture process was the appropriation of an approximately 3-s long interval in the mid-portion of phonation, while discarding the first and last 25 ms of phonation[22]. A 3-s interval was used because this time span is sufficiently long to provide a reliable analysis of most parameters while sustaining the phonation of the vowel with a relatively stable effort and pitch, and it could be readily performed by the participant. Statistical analysis We used the software SPSS statistics–24 (IBM, Chicago, IL, USA) for statistical analysis. Longitudinal changes in acoustic parameters were assessed by comparing the data at BL with those at each timepoint after surgery using Kruskal-Wallis test with Steel post-hoc test with R (http://www.r-project.org/). The differences in vocal functions between the AM and PM conditions were assessed using Wilcoxon signed-rank tests. A p value < 0.05 was considered statistically significant. Results The results of the acoustic analysis are shown in Figure 3 and Table 1. A significant difference after the surgery was observed in Fo for both AM and PM assessments ( p < 0.01), and increased significantly than BL at 3M and 6M (vs. 3M, AM, p < 0.05; vs. 6M, AM, p < 0.05; vs. 3M, PM, p < 0.05; vs. 6M, PM, p < 0.05). NHR and DSH in the PM assessments also showed significant differences (NHR, p < 0.01; DSH, p < 0.001), where the NHR was significantly lower than BL at 3M and 6M (3M, p < 0.01; 6M, p < 0.01), and DSH improved significantly from BL at all postoperative assessments (1M, p < 0.05; 3M, p < 0.05; 6M, p < 0.05). The AM and PM results at each assessment period were compared to reveal a significant difference in DSH at BL, whereas the DSH in the PM assessment was worse than the AM ( p < 0.05). Furthermore, snoring and OSA, which were the chief participant complaints, completely disappeared immediately after the surgery, and movement of the thorax during sleep also normalized. Discussion To the best of our knowledge, this is the first reported case of longitudional vocal change using acoustic analysis after adenotonsillar hypertrophy and adenotonsillectomy. We need to be aware of the possibility that these surgeries may contribute to improving the voice as well as OSA and sleep quality. Vocal tract models have shown that vocal tract stenosis, particularly in the epipharyngeal area, causes reflux against the flow of the air exhaled from the lungs, generating back pressure (BP)[23,24]. BP can occur with adenotonsillar hypertrophy and can affect vocal cord vibration and glottal closure. 14 . We considered that this BP are biggest factor of the changes to the acoustic parameters (Fo, NHR and DSH) in this study. Fo is directly and auditory-perceptually linked to vocal pitch. It’s understood that the pitch of young children’s voices lowers as they grow[25]; however, with this participant, Fo became significantly higher than BL at 3M and 6M postoperatively, contrary to the changes to pitch that should accompany natural physiological changes. Previous studies that followed patients over the course of six postoperative months, as done in this study, have reported significantly higher pitch 10 and a higher average pitch without a significant difference[10], and both studies attributed the higher postoperative pitch to BP. NHR and DSH were also parameters that display postoperative changes. The noise component assessed by NHR is associated with glottal closure insufficiency[26], which is suggested to be caused by BP generated by vocal tract stenosis and consequently higher glottal flow pressure[27]. DSH is reported to be detected when stiffness of some muscles of the vocal cords results in irregular vocal cord vibration[28]. In this study, it may have been caused by high effort in vocalizing against the glottal closure insufficiency that occurred during vocalizations. Since changes to these acoustic parameters (Fo, NHR and DSH) were observed postoperatively, they can be considered as parameters that can detect the effects of adenotonsillar hypertrophy, therefore these parameters are important for pre- and postoperative assessments. However, another aspect that needs to be mentioned in discussing the NHR and DSH is “vocal abuse” which is often observed in small children[15,29]. Changes to these parameters were only observed in the PM assessments, and this pattern may be able to explain by the activities and vocal abuse during the daily living of child. Small children, especially boys, are prone to injuring their throat since they may yell to get what they want, and have difficulty controlling how long or how loudly they speak[30]. This is increasingly plausible for children who spend a lot of time interacting with other children in a nursery school. The AM and PM assessments in this study can also be interpreted as assessments before and after vocal abuse. The changes observed in NHR and DSH also suggest that adenotonsillar hypertrophy may worsen vocal dysfunction associated with vocal abuse. In addition, we considered that adenotonsillectomy is an effective means of protecting vocal function for young children with tonsillar hypertrophy. It is necessary to pay attention to physiological changes in the larynx and vocal abuse in the evaluation of vocal associated with adenotonsillar hypertrophy and adenotonsillectomy for young children, but there are several other factors that should be noted. First, it may be an obstacle to collect stable voice samples from small children if a difficult method is used or the evaluation is performed in an unfamiliar environment. Second, general anesthesia is recommended for adenotonsillectomy, however, this would require tracheal intubation, which can cause injury to the laryngeal mucosa and/or vocal hoarseness[16,31]. Restricted vocalization due to POST and bleeding 1 that occurs after the adenotonsillectomy and hesitation about how to vocalize after surgery are also hurdles that can hinder accurate and objective assessments of vocal function. Overcoming all of these challenges can be extremely difficult, especially in a study involving small children. However, we managed to select simple tasks focused on a sustained vowel, conducted assessments on multiple days for each assessment interval, and performed two assessments on those days. We also followed the child postoperatively for six months so as to minimize the problems characteristic to such studies on small children and complete the study as planned. Although it is one case study, the findings obtained are an important source of information that should provide valuable data for many otorhinolaryngologists to present to reassure young children and their parents considering surgery. The results of this study should be interpreted with caution given that 1) it is based on one case who was a boy, 2) the changes and differences associated with the tonsillar size (severity of the hypertrophy) have not been explored, 3) a postoperative flexible laryngoscopy was not performed to observe the larynx, and 4) reverberation and articulation were not assessed to examine their effects on voice. In particular, the palatine tonsils are unlikely to have any impact on speech characteristics aside from vocal function itself, as they will not impair velopharyngeal closure[32-35] or affect tongue manipulation in the anterior movement for consonant articulation[32]. Therefore, future studies warrant assessments of speech function that takes into account the movements of the soft palate and tongue rather than one that focuses exclusively on vocal function. In summary, this study analyzed the effects of adenotonsillar hypertrophy and adenotonsillectomy on the voice by acoustic analysis, and obtained the following results: 1) Fo was significantly higher than BL at 3 and 6 months postoperatively, and 2) results differed between the AM and PM assessments, where NHR assessed in the afternoon was found to be lower at 3 and 6 months postoperative and DSH was consistently lower than BL starting one month postoperatively. These results suggest that tonsillar hypertrophy stenoses the vocal tract, thereby generating a BP of exhaled air and affecting vocal function; tonsillar hypertrophy can worsen voice abnormalities associated with vocal abuse; the surgery does not have any negative effects on vocal function at least within the first 6 months, and we considered that three acoustic parameters Fo, NHR and DSH are helpful for evaluating the effects of tonsillar hypertrophy and adenotonsillectomy on vocal function in young child. Abbreviations POST, postoperative sore throat; OSA, obstructive sleep apnea; QOL, quality of life; Fo, Average fundamental frequency; STD, Standard deviation of Fo; Jitt, Jitter percent; Shim, Shimmer percent; NHR, Noise-to-harmonic Ratio; FTRI, Fo-tremor intensity index; ATRI, Amplitude tremor intensity index; DSH, Degree of subharmonic segments; DUV, Degree of voiceless. Declarations Ethics approval and consent to participate This study adhered to the Ethics Guidelines for Epidemiological Studies endorsed by the Japanese government and was approved by the Ethics Review Committee of Aichi Gakuin University (no.2020y). Informed consent was obtained from this participant and his mother. Written Consent for publication We received from guardian of participant (mother) to publication in this study. Availability of data and material Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available. Competing interests All authors report no conflicts of interest. Funding Nothing reports. Author’s contributions (1) Research project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the first draft, B. Review and Critique. Y.T.: 1(A-C), 2(A-C), 3A, M.T.: 1(A), 2(C). Acknowledgments We express our sincerest thanks to patient who endured the pain of the surgery and participated in this study to identify the cause of the voice disturbance that occurs with this disease, thereby contributing to advancements in this area. We also express our gratitude to Ms. Ririka for performing the assessments, Dr. Kosumo Matsui (Department of Otorhinolaryngology, Toyota Memorial Hospital) who performed the surgery, and Dr. Meiho Nakayama (Meiho Sleep and Dizziness Clinic) for performing the detailed assessments of OSA. Code availability This study did not use any custom code or software that is not publicly available. References Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngology–head and neck surgery. 2011;144(1):S1-S30. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3):616–620. Tal A, Leiberman A, Margulis G, et al. Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment. Pediatr Pulmonol. 1988;4(3):139–143. Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. American J Crit Care Med. 1988;157(4):1098–1103. Owens J, Opipari L, Nobile C, et al. Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders. Pediatrics. 1998;102(5): 1178–1184. Kurnatowski P, Putyński L, Lapienis M, et al. Neurocognitive abilities in children with adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol. 2006;70(3):419–424. Mora R, Crippa B, Dellepiane M, et al. Effects of adenotonsillectomy on speech spectrum in children. Int J Pediatr Otorhinolaryngol. 2006;71(8):1299–1304. Salami A, Jankowskaet B, Dellepiane M, et al. The impact of tonsillectomy with or without adenoidectomy on speech and voice. Int J Pediatr Otorhinolaryngol. 2008;72(9):1377–1384. Gomaa MA, Mohammed HM, Abdalla AA, et al. Effect of adenoid hypertrophy on the voice and laryngeal mucosa in children. Int J Pediatr Otorhinolaryngol. 2013;77(12):1936–1939. Pinto I, Firmino-Machado J, Castro E, et al. The effects on the acoustic parameters and auditory-perceptive characteristics of voice in children submitted to adenoidectomy with or without tonsillectomy. Int J Pediatr Otorhinolaryngol. 2019;125:51–55. Kenna MA, Bluestone CD, Stool SE. Pediatric otolaryngology. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology 2nd ed, Philadelphia: Saunders; 1996. Chapters 58–59. Titze IR, Story BH. Acoustic interactions of the voice source with the lower vocal tract. J Acoust Soc Am. 1997;101(4):2234–2243. Dimatos SC, Neves LR, Beltrame JM, et al. Impact of adenotonsillectomy on vocal emission in children. Brazi J Otorhinolaryngol. 2016;82(2):151–158. Martins RHG, Branco A, Tavares ELM, et al. Clinical practice: vocal nodules in dysphonic children. Eur J Pediatr. 2013;172(9):1161–1165. McMurray JS. Medical and surgical treatment of pediatric dysphonia. Otolaryngol Clin North Am. 2000;33(5):1111–1125. Kalil DM, Silvestro LS, Austin PN. Novel preoperative pharmacologic methods of preventing postoperative sore throat due to tracheal intubation. AANA J. 2014;82(3):188–197. Shaaban AR, Kamal AM. Comparison between betamethasone gel applied over endotracheal tube and ketamine gargle for attenuating postoperative sore throat, cough and hoarseness of voice. Middle East J Anaesthesiol. 2012;21(4):513–519. Friedman M, Tanyeri H, Rosa ML, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope. 1999;109(12): 1901–1907. Ueno K, Nagoshi N, Onuki S. Picture Vocabulary test-Revised. Tokyo: Nihon Bunka Kagakusha; 2008. TanakaY, Nishio M, Niimi D. Vocal acoustic characteristics of patients with Parkinson’s disease. Folia Phoniatr Logop. 2011;63(5):223–230. Tanaka Y, Tsuboi T, Watanabe H, et al. Voice features of Parkinson’s disease patients with subthalamic nucleus deep brain stimulation. J Neurol. 2015;262(5):1173–1181. Kent RD, Vorperian HK, Kent JF, et al. Voice dysfunction in dysarthria: application of the Multi-Dimensional Voice Program. J Commun Disord. 2003;36(4):281–306. Titze IR. Principles of Voice Production. Boston: Allyn & Bacon; 1994. Titze IR. Voice training and therapy with a semi-occluded vocal tract: rationale and scientific underpinnings. J Speech Lang Hear Res. 2006;49(2): 448–459. Kurita S. Growth, development and aging of the vocal fold. Japan J Logop Phoniatr. 1988;29(2):185–193. Kosztyła-Hojna B, Zdrojkowski M, Duchnowska E. The application of High-Speed camera (HS), acoustic analysis and Voice Handicap Index (VHI) questionnaire in diagnosis of voice disorders in elderly men. Otolaryngol Pol. 2019;73(5):25–30. Titze IR. Phonation threshold pressure measurement with a semi-occluded vocal tract. J Speech Lang Hear Res. 2009;52(4):1062–1072. Švec JG, Schutte HK, Miller DG. A subharmonic vibratory pattern in normal vocal folds. J Speech Lang Hear Res. 1996;39(1):135–143. McMurray JS. Disorders of phonation in children. Pediatr Clinics North Am. 2003;50(2):363–380. Shirai Y, Maekawa K, Suehiro A. Clinical Characteristics of pediatric Vocal cord nodules and adult vocal Fold nodules at the initial evaluation. Japan J Logop Phoniatr. 2021;62(3):215–222. Zhipeng Li, Meiyi H, Meirong W, et al. Ultrasound-guided internal branch of superior laryngeal nerve block on postoperative sore throat: A randomized controlled trial. PLoS One. 2020;15(11): e0241834. Ilk HG, Eroğul O, Satar B, et al. Effects of tonsillectomy on speech spectrum. J Voice. 2002;16(4):580–586. Finkelstein Y, Nachmani A, Ophir D. The functional role of the tonsils in speech. Arch Otolaryngol Head Neck Surg. 1994;120(8):846–851. Abdel-Aziz M, El-Fouly M, Nassar A, et al. The effect of hypertrophied tonsils on the velopharyngeal function in children with normal palate. Int J Pediatr Otorhinolaryngol. 2019;119:59–62. Maryn Y, Van Lierde K, De Bodt M, et al. The effects of adenoidectomy and tonsillectomy on speech and nasal resonance. Folia Phoniatr Logop. 2014;54(3):182–191. Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Supplevideo1.m4a Table1acousticanalyses20240219.docx Checklist.pdf Authorinformation.docx Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2025 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted Editorial decision: Revision requested 07 Sep, 2025 Reviews received at journal 07 Sep, 2025 Reviews received at journal 04 Sep, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers invited by journal 22 Jul, 2025 Editor assigned by journal 22 Jul, 2025 Submission checks completed at journal 22 Jul, 2025 First submitted to journal 21 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7173808","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":489482051,"identity":"4c8d63b4-5469-4173-a5c1-b014734c3777","order_by":0,"name":"Yasuhiro Tanaka","email":"data:image/png;base64,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","orcid":"","institution":"Aichi Gakuin University","correspondingAuthor":true,"prefix":"","firstName":"Yasuhiro","middleName":"","lastName":"Tanaka","suffix":""},{"id":489482052,"identity":"e104cbd9-bdb2-4ded-91fe-a1548c029b6b","order_by":1,"name":"Mayu Tanaka","email":"","orcid":"","institution":"Nagoya University graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mayu","middleName":"","lastName":"Tanaka","suffix":""}],"badges":[],"createdAt":"2025-07-21 06:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7173808/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7173808/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43054-025-00462-8","type":"published","date":"2025-12-08T15:57:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87553249,"identity":"ba1173c9-a742-4a99-a229-4b0ba56374c7","added_by":"auto","created_at":"2025-07-25 06:36:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94464,"visible":true,"origin":"","legend":"\u003cp\u003eLateral x-ray in this participant; White triangle, palatine tonsils; Black triangle, pharyngeal tonsils.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/7657d55826bc6e1924d557ed.jpg"},{"id":87553251,"identity":"72f77f71-e214-4ec5-bfea-f0efb3e83265","added_by":"auto","created_at":"2025-07-25 06:36:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":122592,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoral inspection of the palatine tonsils.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/2cfd75b8e58f9622c581b722.jpg"},{"id":87553250,"identity":"b20f5b73-9f60-4059-bd42-439ad4b5f967","added_by":"auto","created_at":"2025-07-25 06:36:51","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":83806,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in the main acoustic parameters. BL, Base line; M, months after surgery; Fo, Average fundamental frequency; STD, Standard deviation of Fo; Jitt, Jitter percent; Shim, Shimmer percent; NHR, Noise-to-harmonic Ratio; DSH, Degree of subharmonic segments. †\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; Significant longitudinal changes in AM assessments. ‡\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; Significant longitudinal changes in PM assessments. *\u003cem\u003ep \u003c/em\u003e\u0026lt; 0.05; Significant difference between AM and PM assessments.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/bc0f3b4503da539380789fb2.jpg"},{"id":98244905,"identity":"015adcfd-35c6-4c23-8e6a-e9b6ded189a3","added_by":"auto","created_at":"2025-12-15 16:15:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":755389,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/ac902871-382c-44b4-a94e-dc98b2d754a4.pdf"},{"id":87553256,"identity":"73810e35-9724-478e-8919-144a37710744","added_by":"auto","created_at":"2025-07-25 06:36:51","extension":"m4a","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":736872,"visible":true,"origin":"","legend":"","description":"","filename":"Supplevideo1.m4a","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/2aafc4f512c420af99737011.m4a"},{"id":87553253,"identity":"62559168-68be-4304-8601-71dd0378a19d","added_by":"auto","created_at":"2025-07-25 06:36:51","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22925,"visible":true,"origin":"","legend":"","description":"","filename":"Table1acousticanalyses20240219.docx","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/554c0ed4564d15241969af93.docx"},{"id":87553258,"identity":"ca747766-3f53-437e-a860-a42905c8c87a","added_by":"auto","created_at":"2025-07-25 06:36:52","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":647235,"visible":true,"origin":"","legend":"","description":"","filename":"Checklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/b54476b7ed828537e323f6c9.pdf"},{"id":87553257,"identity":"c0a794a5-dc4f-4a40-a386-8498f1b3fd80","added_by":"auto","created_at":"2025-07-25 06:36:51","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":32228,"visible":true,"origin":"","legend":"","description":"","filename":"Authorinformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-7173808/v1/f3572406257f7c20eaf745a1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"CASE REPORT: Vocal acoustic characteristics of adenotonsillar hypertrophy and adenotonsillectomy in young child.","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePharyngeal and palatine tonsils become considerably enlarged in the early childhood. Their tonsillar hypertrophy is because it can cause respiratory disorders and obstructive sleep apnea (OSA)[1], which are linked with substantially affect child health status and quality of life (QoL)[1,2], such as underdevelopment of the thorax, heart failure[3,4], and poor concentrating during the day[5,6]. Furthermore, such tonsillar hypertrophy can trigger voice disturbance[7-9] because mouth-breathing can cause throat dryness and inflammation[10], and tonsillar secretions might cause induce mucosal inflammation of the vocal cords[11]. The location of these tonsils in the upper airway (vocal tract) are inferred that air exhaled for speech can generate air turbulence, thereby affecting the degree of glottal closure[8,12].\u003c/p\u003e\n\u003cp\u003eHowever, there is scant research on objective changes to acoustic parameters associated with adenotonsillar hypertrophy and adenotonsillectomy. Even though some data reveal significant results, the majority of studies; 1) excluded young children, even though tonsillar hypertrophy affects[10,13], 2) are on a wide range of participants ages[7,8,13], 3) fail to investigate the effects associated with vocal abuse or misuse[14,15], and 4) do not take into account the effects of postoperative sore throat (POST) associated with the surgery or tracheal intubation on voice quality[1,16,17], resulting in inconclusive results. We consider that the challenges associated with including child participants in such studies is assumed to be the reason why studies on the topic have not included young children in their analysis.\u003c/p\u003e\n\u003cp\u003eThis study aimed to perform a vocal acoustic analysis on the effects of adenotonsillar hypertrophy and adenotonsillectomy by eliminating these obstacles as much as possible. The valid objective data by acoustic analysis might be able to reduce that those patients and their parents have some concerns about the voice change of after surgery[13], and might help the medical doctors provide a meaningful statement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participant was a boy aged 3 years and 2 months (height, 102.2 cm; weight, 17.1kg) who presented with the chief complaint of habitual snoring (Supplemental video 1) and apnea during sleep. Lateral x-ray showed hypertrophy of the pharyngeal and palatine tonsils (Figure 1) with a severity of 3 on the Friedman\u0026rsquo;s tonsil grading scale (Figure 2)[18]. Flexible laryngoscopy revealed no structural changes or inflammations such as vocal nodules and/or vocal cord polyp, and the patient did not have any subjective symptoms related to vocal function such as discomfort, abnormality, or behavioral abnormality during vocalizations. The Japanese version of Picture Vocabulary Test-revised[19] scaled score was 10, intelligence was evaluated as being at an average level, and the participant had never been noted as having developmental abnormalities in any baby health checkup.\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Ethics Guidelines for Epidemiological Studies endorsed by the Japanese government and was approved by the Ethics Review Committee of Aichi Gakuin University (no.2020y). Informed consent was obtained from this participant and his mother.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVocal function was assessed four times; that is, before the adenotonsillectomy (Base line, BL), and at 1 month (1M), 3 months (3M) and 6 months (6M) postoperatively. The BL assessment was made over 10 days in the 1-month period before the surgery, and the assessments at 1M, 3M, 6M were performed for 5 consecutive days. The assessments were always made during the week on a day when the participant went to nursery school. Assessments on these days were made twice, once in the morning (AM) and once in the afternoon (PM). The AM assessment was made at least 30 min after waking up, and the PM assessment was made by collecting speech samples before dinner and bath time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVoice samples\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sustained vowel /a:/ was taken for the voice sample. The analysis of the sustained vowel followed the procedures of a previous study[20,21]: the mean of two vocalizations of the vowel /a:/ for 5 seconds in a comfortable, habitual pitch and loudness was used as the result. All voice samples were recorded in a sound-treated room and digitized in a voice recorder (ICD-SX813; SONY, Tokyo, Japan) at a sampling rate of 44.1 kHz and 16 bit quantization. A microphone (ECM-MS907; SONY, Tokyo, Japan) was appropriately positioned to maintain a constant mouth-to-microphone distance of 15 cm during speech recording, and the recorded speech samples subsequently used for acoustic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcoustic Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Multi-Dimensional \u003cem\u003eVoice\u003c/em\u003e Program (MDVP; Computerized Speech Lab, CSL; PENTAX Medical, Lincoln Park, NJ) was used to analyze the nine main parameters for the acoustic analysis of the sustained vowel: average fundamental frequency (Fo) and standard deviation of Fo (STD), pitch of voice; jitter percent (Jitt), frequency perturbation measurements; shimmer percent (Shim), amplitude perturbation measurements; noise-to-harmonic ratio (NHR), noise-related measurements; Fo-tremor and amplitude-tremor intensity index (FTRI and ATRI), tremor related measurements; degree of subharmonics (DSH), subharmonic component-related measurements; and degree of voiceless (DUV), voice irregularity-related measurements. The general criterion of the capture process was the appropriation of an approximately 3-s long interval in the mid-portion of phonation, while discarding the first and last 25 ms of phonation[22]. A 3-s interval was used because this time span is sufficiently long to provide a reliable analysis of most parameters while sustaining the phonation of the vowel with a relatively stable effort and pitch, and it could be readily performed by the participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used the software SPSS statistics\u0026ndash;24 (IBM, Chicago, IL, USA) for statistical analysis. Longitudinal changes in acoustic parameters were assessed by comparing the data at BL with those at each timepoint after surgery using Kruskal-Wallis test with Steel \u003cem\u003epost-hoc\u0026nbsp;\u003c/em\u003etest with R (http://www.r-project.org/). The differences in vocal functions between the AM and PM conditions were assessed using Wilcoxon signed-rank tests. A \u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results of the acoustic analysis are shown in Figure 3 and Table 1. A significant difference after the surgery was observed in Fo for both AM and PM assessments (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01), and increased significantly than BL at 3M and 6M (vs. 3M, AM, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; vs. 6M, AM, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; vs. 3M, PM, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; vs. 6M, PM, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). NHR and DSH in the PM assessments also showed significant differences (NHR, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01; DSH, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), where the NHR was significantly lower than BL at 3M and 6M (3M, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01; 6M, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01), and DSH improved significantly from BL at all postoperative assessments (1M, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; 3M, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; 6M, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). The AM and PM results at each assessment period were compared to reveal a significant difference in DSH at BL, whereas the DSH in the PM assessment was worse than the AM (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). Furthermore, snoring and OSA, which were the chief participant complaints, completely disappeared immediately after the surgery, and movement of the thorax during sleep also normalized.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first reported case of longitudional vocal change using acoustic analysis after adenotonsillar hypertrophy and adenotonsillectomy. We need to be aware of the possibility that these surgeries may contribute to improving the voice as well as OSA and sleep quality.\u003c/p\u003e\n\u003cp\u003eVocal tract models have shown that vocal tract stenosis, particularly in the epipharyngeal area, causes reflux against the flow of the air exhaled from the lungs, generating back pressure (BP)[23,24]. BP can occur with\u0026nbsp;adenotonsillar hypertrophy\u0026nbsp;and can affect vocal cord vibration and glottal closure.\u003csup\u003e14\u003c/sup\u003e. We considered that this BP are biggest factor of the changes to the acoustic parameters (Fo, NHR and DSH) in this study.\u003c/p\u003e\n\u003cp\u003eFo is directly and auditory-perceptually linked to vocal pitch. It\u0026rsquo;s understood that the pitch of young children\u0026rsquo;s voices lowers as they grow[25]; however, with this participant, Fo became significantly higher than BL at 3M and 6M postoperatively, contrary to the changes to pitch that should accompany natural physiological changes. Previous studies that followed patients over the course of six postoperative months, as done in this study, have reported significantly higher pitch\u003csup\u003e10\u003c/sup\u003e and a higher average pitch without a significant difference[10], and both studies attributed the higher postoperative pitch to BP.\u003c/p\u003e\n\u003cp\u003eNHR and DSH were also parameters that display postoperative changes. The noise component assessed by NHR is associated with glottal closure insufficiency[26], which is suggested to be caused by BP generated by vocal tract stenosis and consequently higher glottal flow pressure[27]. DSH is reported to be detected when stiffness of some muscles of the vocal cords results in irregular vocal cord vibration[28]. In this study, it may have been caused by high effort in vocalizing against the glottal closure insufficiency that occurred during vocalizations.\u003c/p\u003e\n\u003cp\u003eSince changes to these acoustic parameters (Fo, NHR and DSH) were observed postoperatively, they can be considered as parameters that can detect the effects of adenotonsillar hypertrophy, therefore these parameters are important for pre- and postoperative assessments. However, another aspect that needs to be mentioned in discussing the NHR and DSH is \u0026ldquo;vocal abuse\u0026rdquo; which is often observed in small children[15,29]. Changes to these parameters were only observed in the PM assessments, and this pattern may be able to explain by the activities and\u0026nbsp;vocal abuse\u0026nbsp;during the daily living of child. Small children, especially boys, are prone to injuring their throat since they may yell to get what they want, and have difficulty controlling how long or how loudly they speak[30]. This is increasingly plausible for children who spend a lot of time interacting with other children in a nursery school. The AM and PM assessments in this study can also be interpreted as assessments before and after\u0026nbsp;vocal abuse. The changes observed in NHR and DSH also suggest that adenotonsillar hypertrophy may worsen vocal dysfunction associated with\u0026nbsp;vocal abuse. In addition, we considered that\u0026nbsp;adenotonsillectomy\u0026nbsp;is an effective means of protecting vocal function for young children with tonsillar hypertrophy.\u003c/p\u003e\n\u003cp\u003eIt is necessary to pay attention to physiological changes in the larynx and\u0026nbsp;vocal abuse\u0026nbsp;in the evaluation of vocal associated with adenotonsillar hypertrophy and adenotonsillectomy for young children, but there are several other factors that should be noted. First, it may be an obstacle to collect stable voice samples from small children if a difficult method is used or the evaluation is performed in an unfamiliar environment. Second, general anesthesia is recommended for adenotonsillectomy, however, this would require tracheal intubation, which can cause injury to the laryngeal mucosa and/or vocal hoarseness[16,31]. Restricted vocalization due to POST and bleeding\u003csup\u003e1\u003c/sup\u003e that occurs after the adenotonsillectomy and hesitation about how to vocalize after surgery are also hurdles that can hinder accurate and objective assessments of vocal function.\u003c/p\u003e\n\u003cp\u003eOvercoming all of these challenges can be extremely difficult, especially in a study involving small children. However, we managed to select simple tasks focused on a sustained vowel, conducted assessments on multiple days for each assessment interval, and performed two assessments on those days. We also followed the child postoperatively for six months so as to minimize the problems characteristic to such studies on small children and complete the study as planned. Although it is one case study, the findings obtained are an important source of information that should provide valuable data for many otorhinolaryngologists to present to reassure young children and their parents considering surgery.\u003c/p\u003e\n\u003cp\u003eThe results of this study should be interpreted with caution given that 1) it is based on one case who was a boy, 2) the changes and differences associated with the tonsillar size (severity of the hypertrophy) have not been explored, 3) a postoperative flexible laryngoscopy was not performed to observe the larynx, and 4) reverberation and articulation were not assessed to examine their effects on voice. In particular, the palatine tonsils are unlikely to have any impact on speech characteristics aside from vocal function itself, as they will not impair velopharyngeal closure[32-35] or affect tongue manipulation in the anterior movement for consonant articulation[32]. Therefore, future studies warrant assessments of speech function that takes into account the movements of the soft palate and tongue rather than one that focuses exclusively on vocal function.\u003c/p\u003e\n\u003cp\u003eIn summary, this study analyzed the effects of adenotonsillar hypertrophy and adenotonsillectomy on the voice by acoustic analysis, and obtained the following results: 1) Fo was significantly higher than BL at 3 and 6 months postoperatively, and 2) results differed between the AM and PM assessments, where NHR assessed in the afternoon was found to be lower at 3 and 6 months postoperative and DSH was consistently lower than BL starting one month postoperatively. These results suggest that tonsillar hypertrophy stenoses the vocal tract, thereby generating a BP of exhaled air and affecting vocal function; tonsillar hypertrophy can worsen voice abnormalities associated with vocal abuse; the surgery does not have any negative effects on vocal function at least within the first 6 months, and we considered that three acoustic parameters Fo, NHR and DSH are helpful for evaluating the effects of tonsillar hypertrophy and adenotonsillectomy on vocal function in young child.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePOST, postoperative sore throat; OSA, obstructive sleep apnea; QOL, quality of life; Fo, Average fundamental frequency; STD, Standard deviation of Fo; Jitt, Jitter percent; Shim, Shimmer percent; NHR, Noise-to-harmonic Ratio; FTRI, Fo-tremor intensity index; ATRI, Amplitude tremor intensity index; DSH, Degree of subharmonic segments; DUV, Degree of voiceless.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Ethics Guidelines for Epidemiological Studies endorsed by the Japanese government and was approved by the Ethics Review Committee of Aichi Gakuin University (no.2020y). Informed consent was obtained from this participant and his mother.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWritten Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe received from guardian of participant (mother) to publication in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNothing reports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(1) Research project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the first draft, B. Review and Critique. Y.T.: 1(A-C), 2(A-C), 3A, M.T.: 1(A), 2(C).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our sincerest thanks to patient who endured the pain of the surgery and participated in this study to identify the cause of the voice disturbance that occurs with this disease, thereby contributing to advancements in this area. We also express our gratitude to Ms. Ririka for performing the assessments, Dr. Kosumo Matsui (Department of\u0026nbsp;Otorhinolaryngology, Toyota Memorial Hospital) who performed the surgery, and Dr. Meiho Nakayama (Meiho Sleep and Dizziness Clinic) for performing the detailed assessments of OSA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not use any custom code or software that is not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngology\u0026ndash;head and neck surgery. 2011;144(1):S1-S30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3):616\u0026ndash;620.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTal A, Leiberman A, Margulis G, et al. Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment. Pediatr Pulmonol. 1988;4(3):139\u0026ndash;143.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. American J Crit Care Med. 1988;157(4):1098\u0026ndash;1103.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOwens J, Opipari L, Nobile C, et al. Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders. Pediatrics. 1998;102(5): 1178\u0026ndash;1184.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKurnatowski P, Putyński L, Lapienis M, et al. Neurocognitive abilities in children with adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol. 2006;70(3):419\u0026ndash;424.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMora R, Crippa B, Dellepiane M, et al. Effects of adenotonsillectomy on speech spectrum in children. Int J Pediatr Otorhinolaryngol. 2006;71(8):1299\u0026ndash;1304.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalami A, Jankowskaet B, Dellepiane M, et al. The impact of tonsillectomy with or without adenoidectomy on speech and voice. Int J Pediatr Otorhinolaryngol. 2008;72(9):1377\u0026ndash;1384.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGomaa MA, Mohammed HM, Abdalla AA, et al. Effect of adenoid hypertrophy on the voice and laryngeal mucosa in children. Int J Pediatr Otorhinolaryngol. 2013;77(12):1936\u0026ndash;1939.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePinto I, Firmino-Machado J, Castro E, et al. The effects on the acoustic parameters and auditory-perceptive characteristics of voice in children submitted to adenoidectomy with or without tonsillectomy. Int J Pediatr Otorhinolaryngol. 2019;125:51\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKenna MA, Bluestone CD, Stool SE. Pediatric otolaryngology. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology 2nd ed, Philadelphia: Saunders; 1996. Chapters 58\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTitze IR, Story BH. Acoustic interactions of the voice source with the lower vocal tract. J Acoust Soc Am. 1997;101(4):2234\u0026ndash;2243.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDimatos SC, Neves LR, Beltrame JM, et al. Impact of adenotonsillectomy on vocal emission in children. Brazi J Otorhinolaryngol. 2016;82(2):151\u0026ndash;158.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartins RHG, Branco A, Tavares ELM, et al. Clinical practice: vocal nodules in dysphonic children. Eur J Pediatr. 2013;172(9):1161\u0026ndash;1165.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcMurray JS. Medical and surgical treatment of pediatric dysphonia. Otolaryngol Clin North Am. 2000;33(5):1111\u0026ndash;1125.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalil DM, Silvestro LS, Austin PN. Novel preoperative pharmacologic methods of preventing postoperative sore throat due to tracheal intubation. AANA J. 2014;82(3):188\u0026ndash;197.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShaaban AR, Kamal AM. Comparison between betamethasone gel applied over endotracheal tube and ketamine gargle for attenuating postoperative sore throat, cough and hoarseness of voice. Middle East J Anaesthesiol. 2012;21(4):513\u0026ndash;519.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFriedman M, Tanyeri H, Rosa ML, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope. 1999;109(12): 1901\u0026ndash;1907.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUeno K, Nagoshi N, Onuki S. Picture Vocabulary test-Revised. Tokyo: Nihon Bunka Kagakusha; 2008.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTanakaY, Nishio M, Niimi D. Vocal acoustic characteristics of patients with Parkinson\u0026rsquo;s disease. Folia Phoniatr Logop. 2011;63(5):223\u0026ndash;230.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTanaka Y, Tsuboi T, Watanabe H, et al. Voice features of Parkinson\u0026rsquo;s disease patients with subthalamic nucleus deep brain stimulation. J Neurol. 2015;262(5):1173\u0026ndash;1181.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKent RD, Vorperian HK, Kent JF, et al. Voice dysfunction in dysarthria: application of the Multi-Dimensional Voice Program. J Commun Disord. 2003;36(4):281\u0026ndash;306.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTitze IR. Principles of Voice Production. Boston: Allyn \u0026amp; Bacon; 1994.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTitze IR. Voice training and therapy with a semi-occluded vocal tract: rationale and scientific underpinnings. J Speech Lang Hear Res. 2006;49(2): 448\u0026ndash;459.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKurita S. Growth, development and aging of the vocal fold. Japan J Logop Phoniatr. 1988;29(2):185\u0026ndash;193.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKosztyła-Hojna B, Zdrojkowski M, Duchnowska E. The application of High-Speed camera (HS), acoustic analysis and Voice Handicap Index (VHI) questionnaire in diagnosis of voice disorders in elderly men. Otolaryngol Pol. 2019;73(5):25\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTitze IR. Phonation threshold pressure measurement with a semi-occluded vocal tract. J Speech Lang Hear Res. 2009;52(4):1062\u0026ndash;1072.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eŠvec JG, Schutte HK, Miller DG. A subharmonic vibratory pattern in normal vocal folds. J Speech Lang Hear Res. 1996;39(1):135\u0026ndash;143.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcMurray JS. Disorders of phonation in children. Pediatr Clinics North Am. 2003;50(2):363\u0026ndash;380.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShirai Y, Maekawa K, Suehiro A. Clinical Characteristics of pediatric Vocal cord nodules and adult vocal Fold nodules at the initial evaluation. Japan J Logop Phoniatr. 2021;62(3):215\u0026ndash;222.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhipeng Li, Meiyi H, Meirong W, et al. Ultrasound-guided internal branch of superior laryngeal nerve block on postoperative sore throat: A randomized controlled trial. PLoS One. 2020;15(11): e0241834.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIlk HG, Eroğul O, Satar B, et al. Effects of tonsillectomy on speech spectrum. J Voice. 2002;16(4):580\u0026ndash;586.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFinkelstein Y, Nachmani A, Ophir D. The functional role of the tonsils in speech. Arch Otolaryngol Head Neck Surg. 1994;120(8):846\u0026ndash;851.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdel-Aziz M, El-Fouly M, Nassar A, et al. The effect of hypertrophied tonsils on the velopharyngeal function in children with normal palate. Int J Pediatr Otorhinolaryngol. 2019;119:59\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaryn Y, Van Lierde K, De Bodt M, et al. The effects of adenoidectomy and tonsillectomy on speech and nasal resonance. Folia Phoniatr Logop. 2014;54(3):182\u0026ndash;191.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Voice, Acoustic analysis, Adenoids, Obstructive sleep apnea, Tonsillar hypertrophy","lastPublishedDoi":"10.21203/rs.3.rs-7173808/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7173808/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdenotonsillar hypertrophy, which is the cause of the majority of sleep disorders in children, can cause various problems. One of the symptoms is a voice disorder, but the details remain unclear. The reasons 1) excluded young children (3-6 y.o.), even though tonsillar hypertrophy affects from previous studies, 2) are on a wide range of participants ages, 3) fail to investigate the effects associated with vocal abuse or misuse, and 4) do not take into account the effects of postoperative sore throat (POST) associated with the surgery or tracheal intubation on voice quality, resulting in inconclusive results. This study aimed to perform a vocal acoustic analysis on the effects of adenotonsillar hypertrophy and adenotonsillectomy by eliminating these obstacles as much as possible. The results of this study will help to recognize the type of this symptoms-related voice disorders, and information based on acoustical objective indexes for medical doctors, patients, and their families.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe collected the vocalizations of patient, he was a boy aged three years, for the 10 days before the surgery, and for five days at 1, 3, and 6 months postoperatively. Voices were recorded twice, once in the morning (AM) and once in the evening (PM), and used for acoustic analysis. Although this is a single case, no previous report has investigated the effects of adenoids on voice in such a long-term and detailed manner, and it’s a valuable report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe parameters indicating voice pitch (fundamental frequency: Fo), glottic insufficiency (noise-to-harmonic ratio: NHR), and vocal fold stiffness (degree of subharmonic: DSH) improved after surgery. These results suggested that the tonsillar hypertrophy may contribute to the phonotrauma, and adenotonsillectomy seems to have positive effect not only on the improvement of obstructive sleep apnea (OSA) in child, but also on the development of voice.\u003c/p\u003e","manuscriptTitle":"CASE REPORT: Vocal acoustic characteristics of adenotonsillar hypertrophy and adenotonsillectomy in young child.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 06:36:47","doi":"10.21203/rs.3.rs-7173808/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T03:52:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T20:15:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-04T09:29:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297020849256955622791066580121070134929","date":"2025-08-27T16:52:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121950447126382549308138653306157964766","date":"2025-08-26T21:20:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198967704073954134484542191896216542433","date":"2025-07-29T00:48:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-22T13:51:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-22T09:31:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-22T09:28:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Egyptian Pediatric Association Gazette","date":"2025-07-21T06:13:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d2ee0316-93f8-4562-9da5-5ae643812713","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:11:01+00:00","versionOfRecord":{"articleIdentity":"rs-7173808","link":"https://doi.org/10.1186/s43054-025-00462-8","journal":{"identity":"egyptian-pediatric-association-gazette","isVorOnly":false,"title":"Egyptian Pediatric Association Gazette"},"publishedOn":"2025-12-08 15:57:25","publishedOnDateReadable":"December 8th, 2025"},"versionCreatedAt":"2025-07-25 06:36:47","video":"","vorDoi":"10.1186/s43054-025-00462-8","vorDoiUrl":"https://doi.org/10.1186/s43054-025-00462-8","workflowStages":[]},"version":"v1","identity":"rs-7173808","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7173808","identity":"rs-7173808","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}