Hoarseness

Hoarseness is best defined as any change in vocal quality. It is a common pediatric complaint and is usually associated with self-limited conditions. In some instances there may be serious underlying entities that require intervention.

Common Etiologies of Hoarseness

  1. Voice overuse: Often seen after screaming or cheering at an athletic event.
  2. Laryngitis: Usually associated with upper respiratory infection and symptoms of cough, runny nose, and low grade fever.
  3. Anatomic lesions: vocal cord nodules (screamers' nodes), laryngeal cysts, webs and clefts, tumors, papillomas etc.
  4. Secondary to intubation: Patient may have edema, granuloma formation, arytenoid dislocation, cord dysfunction, and subglottic stenosis
  5. Trauma to the neck and larynx: Trauma may produce mucosal lesions including hematomas which heal by fibrosis into nodules.
  6. In infants, vocal cord paralysis may be secondary to traumatic delivery (often forceps) or associated with Arnold Chiari malformation.
  7. Post surgery e.g. cardiac, thyroid, and TEF repair.
  8. Allergic laryngitis
  9. Syphilis and Tuberculosis
  10. Neurologic causes including both peripheral and central lesions
  11. Miscellaneous causes: GER, reactive airway disease, smoke inhalation, caustic ingestion, genetic syndromes such as Williams syndrome, De Lange syndrome and Farber disease.


History: The history can help to narrow the differential diagnosis.

  1. Age of onset? prematurity? (can help differentiate congenital from acquired lesions)
  2. Vocal quality (e.g. breathy, alteration in pitch)
  3. Duration of symptoms? (acute changes suggest trauma or inflammation while chronic changes suggest a structural lesion)
  4. History of intubation? ventilator use? respiratory failure?
  5. History consistent with foreign body aspiration (e.g. sudden onset)
  6. Concurrent illness and symptoms
  7. Intermittent or seasonal symptoms may suggest allergies.


Physical Examination

  1. Listen to the speech and breathing of the child to detect the presence of hoarseness
  2. Examine the oropharynx, ears, nose, and neck
  3. Ascertain if the child is having respiratory difficulties, stridor, SOB, retractions. Immediate intubation (emergency) might be needed if the child is drooling, gasping, propped or leaning forward or using accessory muscles to breath.


Evaluation/Diagnosis

  1. If the child has a URI, no treatment is needed, only supportive measures. If the symptoms persist, may need ENT
  2. If there is evidence of respiratory compromise, an ENT evaluation should be done immediately.
  3. Association with trauma should have an ENT evaluation.
  4. Neonates with hoarseness need immediate ENT evaluation.
  5. ENT may do either indirect laryngoscopy or flexible laryngoscopy evaluation. If child is cooperative, may do under local conditions.
  6. Chest X-ray or CT may be used if a mass lesion is suspected, barium swallow may be helpful in the diagnosis of dysphagia or reflux or in outlining a mass. MRI can help in identifying soft tissue masses.
  7. Fluoroscopy


Treatment – depends on the diagnosis

  1. If there is no airway compromise, observation for a period of time is sufficient. Viral causes are generally self-limiting, and symptomatic treatment is sufficient.
  2. Respiratory distress: Patient may need to be intubated or have a tracheotomy performed.
  3. Anatomic lesions and foreign bodies: Surgery may be necessary.
  4. Unilateral vocal cord paralysis may improve spontaneously but if it is bilateral, patient will need a tracheotomy.
  5. Chronic vocal strain: voice retraining with a speech therapist may be required


References

  1. Hastriter EV., Olsson JM. In Brief: Hoarseness. Pediatrics in Review. 2006 Jun;27(6):e47-e48
  2. Kenna, Margaret A. Hoarseness. Pediatrics in Review. February 1995.
  3. Cohen LF. Stridor and Upper Airway Obstruction in Children. Pediatrics in Review. 2000; 21:4-5.