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Hoarseness in Children 1Mary Worthen, 2Swapna Chandran IJHNS Mary Worthen, Swapna Chandran 10.5005/jp-journals-10001-1278 REVIEW ARTICLE Hoarseness in Children 1Mary Worthen, 2Swapna Chandran ABSTRACT thinking in vocal fold pathology leading to hoarseness and recent advances in diagnosis and management. Background: The prevalence of pediatric dysphonia ranges from 6-23%. Chronic dysphonia can negatively affect the lives of children physically, socially, and emotionally. The body of ASSESSMENT OF DYSPHONIA literature continues to grow regarding the pathophysiology and Perceptual analysis is a key component of voice evaluation management of dysphonic children. in children, and several tools are currently available for Methods: This article presents a relevant literature review of assessing these qualities.3 Perceptual analysis of voice by vocal fold pathology leading to hoarseness and recent advances in diagnosis and management. Articles were retrieved using the patient, the parent, the clinician and speech language a selective search in PubMed employing the terms such as pathologist is important in the comprehensive assessment “hoarseness in children,” “pediatric dysphonia.” of pediatric hoarseness. Parental questionnaires such as Results: 42 articles from the past decade were reviewed that the Pediatric Voice outcome Survey, the Pediatric Voice- include information regarding the etiology, assessment, and Related Quality of Life questionnaire, and the Pediatric treatment of children with dysphonia. Voice Handicap Index are available. In these surveys, the Conclusion: The care of a child with a voice disorder can be child’s self-evaluation is not considered. Verduyckt et al complex and requires a multi-disciplinary approach. Current developed a questionnaire to analyze the discriminatory technological, pharmaceutical, and therapeutic advances have capacity of 5- to 13-year-old dysphonic children. They improved the treatment of children with dysphonia. demonstrated the need for a standardized questionnaire Keywords: Hoarseness in children, Pediatric dysphonia, permitting self-evaluation of the child’s voice.4 Pediatric hoarseness. Visualization of the larynx is critical for accurate How to cite this article: Worthen M, Chandran S. Hoarseness diagnosis and management of pediatric dysphonia. In in Children. Int J Head Neck Surg 2016;7(2):130-135. most children, this can be done in the clinic and does not Source of support: Nil require examination under anesthesia. Videolaryngos- Conflict of interest: None troboscopy (VLS) with a rigid endoscope is a standard technique used in adult patients with dysphonia. Video- INTRODUCTION laryngostroboscopy elucidates subtle features of differ- “Hoarseness” and “dysphonia” are terms used to ent disease processes and clarifies differences between describe changes in voice quality. In the pediatric benign mucosal disorders and inflammatory processes population, the prevalence of hoarseness ranges from that contribute to dysphonia. Compared with adults, 6 to 23% of 4- to 12-year-old children. The etiology of children have shorter phonation times, shorter atten- hoarseness can be classified as infectious, inflammatory, tion spans, difficulty completing vocal tasks, and small iatrogenic, traumatic, congenital, and functional.1 Chronic larynges, all making visualization difficult. Therefore, dysphonia can negatively affect the lives of children flexible fiberoptic endoscopy is more frequently used in physically, socially, and emotionally. In contrast to the children.5 Current technology allows VLS with a flex- commonly held belief that children do not appear aware ible fiberoptic nasopharyngoscope. Furthermore, many or concerned about the sound of their voices, children as digital endoscopy systems allow the storing, replaying, young as 6 years express concerns about dysphonia.2 This and comparing of archived images, which provides a article presents a relevant literature review of the current more objective evaluation.6 In one study of 150 children aged 2.5 to 14 years, VLS was successfully performed in all but one child.7 High-speed imaging of the larynx as 1 2 MD, Resident well as laser projection systems have been described to 1,2 Department of Otolaryngology—Head and Neck Surgery enhance measurements of pediatric vocal fold vibratory and Communicative Disorders, University of Louisville School patterns, length, and amplitude.8,9 Wang et al10 used ultra- of Medicine, University of Louisville, Louisville, Kentucky, USA sonography to diagnose pediatric vocal fold paralysis Corresponding Author: Swapna Chandran, Resident Department of Otolaryngology—Head and Neck Surgery and and found it to be a reliable assessment tool in unilateral Communicative Disorders, University of Louisville School of paralysis. Bisetti et al11 used ultrasound to compare Medicine, University of Louisville, Louisville, Kentucky, USA the true vocal fold with flexible endoscopic images in Phone: 15025617268, e-mail: [email protected] 16 children with dysphonia and found the vast majority 130 IJHNS Hoarseness in Children of cases were in agreement, although ultrasound was by Martins et al, 304 children aged 7 to 9 were evaluated unable to differentiate the type of lesion. endoscopically. Epidermal cysts were the second most common mucosal lesions diagnosed. A total of 57% of BENIGN MUCOSAL LESIONS AND OTHER lesions were nodules, while 15.4% had epidermal cysts. BENIGN TUMORS OF THE LARYNX Both lesions were associated with other findings such as mucosal bridges and sulci.1 While acquired benign Mass lesions that involve the membranous vocal folds lesions are often caused by vocal trauma or abuse, it is still and cause dysphonia in children include nodules, unclear why some children develop nodules vs cysts. The cysts (mucoid or epidermoid), polyps, webs, and sulcus type of vocal habit may play a role. For example, children vocalis. In children, the vast majority of vocal changes with vocal nodules often have hard glottal attacks and are secondary to phonotrauma leading to vocal nodules significant strain when phonating. that can be managed conservatively with education Vocal cord polyps are rarely seen in children. Vocal (vocal hygiene) and voice therapy.1 Vocal nodules develop cord polyps occur in the superficial layer of the lamina from repeated trauma to the vocal cords, resulting in an propria; they are usually unilateral and located at the inflammatory reaction and damage to the epithelium and lamina propria. They are often bilateral and commonly junction of the anterior one-third and posterior two- located at the junction of the anterior one-third and thirds of the vocal cord. Traditionally, surgery has been posterior two-thirds of the vocal fold where pressure of the mainstay of treatment for vocal cord polyps, although contact between the vocal cords is greatest.12 Respiratory a Korean study evaluated 248 patients with vocal cord symptoms, such as nasal obstruction leading to chronic polyps and 94 were treated conservatively with vocal mouth breathing and gastroesophageal reflux can be hygiene and laryngopharyngeal reflux (LPR) treat- related to the development of vocal nodules.13,14 ment measures. In 43% of polyps, there was a reduc- Vocal cord nodules most commonly occur in males tion in size and 36% resolved completely without surgery. due to vocal abuse caused by behavioral and structural The majority of patients were female with small, recent- 19 differences compared with females. However, vocal onset polyps. nodules in females are more likely to persist with age Sulcus vocalis is a rare lesion affecting one or both of due to differences in glottic growth. During puberty, the mucosal surfaces of the vocal folds. It is characterized the vocal cords have greater elongation and the thyroid by a linear groove on the mucosal surface of the vocal fold cartilage becomes more acute in males.1,15 Speech therapy with varying depths, at times approaching or touching is the most widely accepted treatment for vocal fold the vocal ligament. Controversy exists regarding the nodules in males and females. In one prospective study, etiology of sulcus vocalis, but theories include congenital, the effect of voice therapy in a cohort of 39 children with chronic inflammation, LPR, and iatrogenic causes. Several vocal cord nodules was examined via VLS and revealed studies have identified a genetic origin. Many times a significant improvements.16 Microlaryngeal surgery sulcus is missed in the initial exam and found at the time may be indicated for highly dysfunctional or persistent of surgery under microscopy, although better imaging nodules. When surgical intervention is performed, vocal techniques currently allow for visualization in the office. nodules can recur in as little as 3 days if poor vocal In many cases, surgical management offers improvement 20 habits are not improved with speech therapy.17 When a in dysphonia in these children. child with “nodules” does not respond to treatment, it is Vocal cord granulomas are benign inflammatory important to consider alternative diagnosis.5 lesions and typically located in the posterior glottis Vocal cysts are classified into epidermic or mucus and associated with the arytenoid cartilages. They are retention cysts. Epidermic cysts are diagnosed by the often iatrogenic and caused by prolonged or traumatic presence of vascular dilation on their surface and intubation. Chronic inflammation secondary to LPR, described as pearly lesions that decrease vibratory wave habitual throat clearing, and vocal abuse are also factors on videostroboscopy.6,13
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