Common causes of hoarseness in children
- Craig H Zalvan, MD
Craig H Zalvan, MD
- Associate Professor
- New York Medical College
- Jacqueline Jones, MD
Jacqueline Jones, MD
- Pediatric Otolaryngology
- Private Practice
Common causes of hoarseness in children (table 1) and an overview of their management will be reviewed here. Other related issues, including laryngeal anatomy, the physiology of phonation, and the evaluation of the child with hoarseness are discussed separately. (See "Hoarseness in children: Evaluation".)
"Hoarseness" or "dysphonia" are terms used to describe a change in the quality of the voice. The voice quality can be raspy, breathy, strained, fatigued, rough, tremulous, or weak. There may be a change in pitch, restriction of range, voice breaks, decreased projection, or abnormal resonance. The prevalence of hoarseness in children ranges from 4 to 23 percent [1-3]. Hoarseness can be caused by any process that affects the structure or function of the larynx. (See "Hoarseness in children: Evaluation", section on 'Physiology'.)
Etiologic categories of hoarseness include infection, inflammation, trauma, obstruction or infiltration, and congenital anomalies (table 1) . In children, hoarseness is most often due to a benign or self-limited cause (eg, viral upper respiratory infection or vocal abuse and misuse) and can be managed with education, watchful waiting, and voice therapy. In addition, the growth of the vocal folds and laryngeal apparatus, change in habits, and change in the hormonal milieu that occur during puberty often contribute to improved voice quality. Surgery is reserved for persistent lesions with noted anatomic alterations.
Hoarseness in children is most often because of benign lesions of the vocal folds (eg, nodules, polyps, hemorrhage, hematoma).
Nodules — Vocal fold nodules are the most common cause of chronic hoarseness in school-aged children . The majority of these lesions occur in boys, particularly at the age of nine years . Vocal fold nodules usually are located on the anterior-free edge of the vocal fold at the point of greatest amplitude of vibration (the junction of the anterior one-third and the posterior two-thirds of the vocal fold) (picture 1). They develop from repeated trauma and abuse to the vocal folds (eg, screaming or shouting) that cause an inflammatory reaction with fibrotic healing. Vocal fold nodules are bilateral and can range in size from slightly raised hyperkeratotic lesions to larger broad-based lesions that prevent closure of the vocal folds. Stroboscopy can best examine and define the nature of laryngeal lesions. In the case of vocal fold nodules, the mucosal wave should remain intact. Nodules can be confused with mid-vocal fold fibrotic lesions and congenital lesions with contralateral reactive lesions.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Silverman EM. Incidence of chronic hoarseness among school-age children. J Speech Hear Disord 1975; 40:211.
- Duff MC, Proctor A, Yairi E. Prevalence of voice disorders in African American and European American preschoolers. J Voice 2004; 18:348.
- Carding PN, Roulstone S, Northstone K, ALSPAC Study Team. The prevalence of childhood dysphonia: a cross-sectional study. J Voice 2006; 20:623.
- Cohen SR, Thompson JW, Geller KA, Birns JW. Voice change in the pediatric patient. A differential diagnosis. Ann Otol Rhinol Laryngol 1983; 92:437.
- Levitsky SE. Hoarseness. In: Primary pediatric care, 4th ed, Hoekelman RA (Ed), Mosby, St. Louis 2001. p.1156.
- Cornut G, Troillet-Cornut A. Childhood dysphonia: clinical and therapeutic considerations. Voice 1995; 4:70.
- von Leden H. Vocal nodules in children. Ear Nose Throat J 1985; 64:473.
- Wohl DL. Nonsurgical management of pediatric vocal fold nodules. Arch Otolaryngol Head Neck Surg 2005; 131:68.
- Reilly JS. The "singing-acting" child: the laryngologist's perspective--1995. J Voice 1997; 11:126.
- Bastian RW. Benign mucosal disorders. In: Otolaryngology head and neck surgery, Cummings CW, Frederickson JM, Harker LA, et al (Eds), Mosby, St. Louis 1986. p.1965.
- Benjamin B, Croxson G. Vocal cord granulomas. Ann Otol Rhinol Laryngol 1985; 94:538.
- Ward PH, Zwitman D, Hanson D, Berci G. Contact ulcers and granulomas of the larynx: new insights into their etiology as a basis for more rational treatment. Otolaryngol Head Neck Surg (1979) 1980; 88:262.
- Kalach N, Gumpert L, Contencin P, Dupont C. Dual-probe pH monitoring for the assessment of gastroesophageal reflux in the course of chronic hoarseness in children. Turk J Pediatr 2000; 42:186.
- de Gaudemar I, Roudaire M, François M, Narcy P. Outcome of laryngeal paralysis in neonates: a long term retrospective study of 113 cases. Int J Pediatr Otorhinolaryngol 1996; 34:101.
- Daya H, Hosni A, Bejar-Solar I, et al. Pediatric vocal fold paralysis: a long-term retrospective study. Arch Otolaryngol Head Neck Surg 2000; 126:21.
- Kenna MA. Consultation with the specialist. Hoarseness. Pediatr Rev 1995; 16:69.
- Shah RK, Harvey-Woodnorth G, Glynn A, Nuss RC. Perceptual voice characteristics in pediatric unilateral vocal fold paralysis. Otolaryngol Head Neck Surg 2006; 134:618.
- Jabbour J, Uhing M, Robey T. Vocal fold paralysis in preterm infants: prevalence and analysis of risk factors. J Perinatol 2017; 37:585.
- Strychowsky JE, Rukholm G, Gupta MK, Reid D. Unilateral vocal fold paralysis after congenital cardiothoracic surgery: a meta-analysis. Pediatrics 2014; 133:e1708.
- Jacobs IN, Finkel RS. Laryngeal electromyography in the management of vocal cord mobility problems in children. Laryngoscope 2002; 112:1243.
- Wang CC, Chang MH, Wang CP, Liu SA. Prognostic indicators of unilateral vocal fold paralysis. Arch Otolaryngol Head Neck Surg 2008; 134:380.
- Lesnik M, Thierry B, Blanchard M, et al. Idiopathic bilateral vocal cord paralysis in infants: Case series and literature review. Laryngoscope 2015; 125:1724.
- Forrest LA, Weed H. Candida laryngitis appearing as leukoplakia and GERD. J Voice 1998; 12:91.
- Chan RW, Tayama N. Biomechanical effects of hydration in vocal fold tissues. Otolaryngol Head Neck Surg 2002; 126:528.
- Block BB, Brodsky L. Hoarseness in children: the role of laryngopharyngeal reflux. Int J Pediatr Otorhinolaryngol 2007; 71:1361.
- Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope 2001; 111:1313.
- Baker J. Psychogenic dysphonia: peeling back the layers. J Voice 1998; 12:527.
- Woodward GA. Neck trauma. In: Textbook of pediatric emergency medicine, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p.1389.
- Tasca RA, Clarke RW. Recurrent respiratory papillomatosis. Arch Dis Child 2006; 91:689.
- Armstrong LR, Derkay CS, Reeves WC. Initial results from the national registry for juvenile-onset recurrent respiratory papillomatosis. RRP Task Force. Arch Otolaryngol Head Neck Surg 1999; 125:743.
- Shah KV, Stern WF, Shah FK, et al. Risk factors for juvenile onset recurrent respiratory papillomatosis. Pediatr Infect Dis J 1998; 17:372.
- Kashima HK, Shah F, Lyles A, et al. A comparison of risk factors in juvenile-onset and adult-onset recurrent respiratory papillomatosis. Laryngoscope 1992; 102:9.
- Quick CA, Watts SL, Krzyzek RA, Faras AJ. Relationship between condylomata and laryngeal papillomata. Clinical and molecular virological evidence. Ann Otol Rhinol Laryngol 1980; 89:467.
- Silverberg MJ, Thorsen P, Lindeberg H, et al. Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis. Obstet Gynecol 2003; 101:645.
- Dedo HH, Yu KC. CO(2) laser treatment in 244 patients with respiratory papillomas. Laryngoscope 2001; 111:1639.
- Parsons DS, Bothwell MR. Powered instrument papilloma excision: an alternative to laser therapy for recurrent respiratory papilloma. Laryngoscope 2001; 111:1494.
- Hartnick CJ, Boseley ME, Franco RA Jr, et al. Efficacy of treating children with anterior commissure and true vocal fold respiratory papilloma with the 585-nm pulsed-dye laser. Arch Otolaryngol Head Neck Surg 2007; 133:127.
- Derkay CS, Wiatrak B. Recurrent respiratory papillomatosis: a review. Laryngoscope 2008; 118:1236.
- Lieder A, Khan MK, Lippert BM. Photodynamic therapy for recurrent respiratory papillomatosis. Cochrane Database Syst Rev 2014; :CD009810.
- Pransky SM, Albright JT, Magit AE. Long-term follow-up of pediatric recurrent respiratory papillomatosis managed with intralesional cidofovir. Laryngoscope 2003; 113:1583.
- Mandell DL, Arjmand EM, Kay DJ, et al. Intralesional cidofovir for pediatric recurrent respiratory papillomatosis. Arch Otolaryngol Head Neck Surg 2004; 130:1319.
- McMurray JS, Connor N, Ford CN. Cidofovir efficacy in recurrent respiratory papillomatosis: a randomized, double-blind, placebo-controlled study. Ann Otol Rhinol Laryngol 2008; 117:477.
- Chadha NK, James A. Adjuvant antiviral therapy for recurrent respiratory papillomatosis. Cochrane Database Syst Rev 2012; 12:CD005053.
- Sidell DR, Nassar M, Cotton RT, et al. High-dose sublesional bevacizumab (avastin) for pediatric recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol 2014; 123:214.
- Zeitels SM, Casiano RR, Gardner GM, et al. Management of common voice problems: Committee report. Otolaryngol Head Neck Surg 2002; 126:333.
- MUCOSAL LESIONS
- Muscle tension dysphonia
- VOCAL FOLD GRANULOMA
- VOCAL FOLD PARALYSIS
- Clinical features
- - Unilateral paralysis
- - Bilateral paralysis
- Acute laryngitis
- Acute laryngotracheitis
- Chronic laryngitis
- GASTROESOPHAGEAL REFLUX/LARYNGOPHARYNGEAL REFLUX
- CONGENITAL ANOMALIES
- PSYCHOGENIC CAUSES
- Paradoxical vocal fold motion
- Mucosal injury
- Intubation injury
- Blunt neck trauma
- Penetrating trauma
- Benign tumors
- - Papillomatosis (HPV)
- Malignant tumors
- INFORMATION FOR PATIENTS