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Hoarseness

Hoarsenessrefers to a raspy or harsh-sounding voice, which is produced bylesions that involve vocal cords.

Same lesions that produce hoarsenessmay sometimes produce stridor, depending on size and location oflesion and age of child.

Principal Causes of Hoarseness

1. Congenitalanomalies of the larynx
   1. Laryngomalacia
   2. Laryngeal web, cyst, or cleft
   3. Laryngocele
2. Infection/inflammation
   1. Laryngitis
   2. Croup
   3. Supraglottitis
3. Allergic disorders
4. Trauma
   1. Vocal abuse
   2. Intubation
   3. Caustic substances and burns
   4. Blunt neck trauma
   5. Airway suctioning and passing of feedingtubes
   6. Foreign body
5. Vocal cord paralysis
6. Gastroesophageal reflux
7. Neoplasm

Clinical Features and Diagnosis

Congenital Anomalies of Larynx

Certain anomalies—laryngomalacia,laryngeal web, laryngeal cyst, laryngeal cleft, and laryngocele—mayproduce hoarseness as well as stridor. See Chap. 63, Stertor, Stridor, and Airway Obstruction.

Infection/Inflammation

Laryngitis

Acute virallaryngitis is frequent cause of episodic hoarseness in children.Usually occurs during course of viral upper respiratory infectionand often subsides within 1 wk. Diagnosis is usually clinical.

C. diphtheriae infection is rare cause.History usually reveals lack of immunization against this pathogen.Nasal discharge and grayish membrane that covers pharynx, tonsils,and larynx or just larynx in ill-appearing child are usual findings.Positive culture of discharge is diagnostic.

Infection with Candida species thatinvolves larynx may occur in individuals who have been treated withprolonged course of antibiotics or who are immunocompromised. Whitepatches may be seen on larynx with flexible laryngoscopy. PositiveKOH preparation or fungal culture is diagnostic.

Croup

Viral croup can produce mild hoarseness,but this disease is characterized more by barking cough and inspiratorystridor. See Chap. 63, Stertor,Stridor, and Airway Obstruction.

Supraglottitis

Hoarseness also can occur with supraglottitis,but acute onset of fever, inspiratory stridor, and drooling aremore characteristic of this illness. See Chap. 63, Stertor, Stridor, and Airway Obstruction.

Allergic Disorders

Any allergicreaction can produce acute laryngeal edema and hoarseness.

History and physical exam are diagnostic.

Trauma

Vocal Abuse

Overuseof voice from singing or shouting is most common cause of transienthoarseness.

Vocal nodules, which are small whiteprotuberances on free margins of true vocal cords, may develop afterprolonged vocal use and cause persistent hoarseness. May be visualizedby flexible laryngoscopy.

Intubation

Endotrachealintubation is common cause of vocal cord ulceration and granuloma formation.

Prolonged intubation can cause vocalcord paralysis and subglottic stenosis.

The former may be diagnosed by flexiblelaryngoscopy, while the latter is usually diagnosed by combinationof neck radiographs, laryngoscopy, and bronchoscopy.

Caustic Substances and Burns

Ingestionof caustic substances and inhalation burns can cause inflammationof larynx and vocal cords.

History, physical exam, and laryngoscopyare diagnostic.

Blunt Neck Trauma

Can causethyroid or cricoid cartilage fractures, arytenoid dislocation, hematomaof larynx, and vocal cord injury.

Awake flexible laryngoscopy is vitaltool for evaluation of suspected laryngeal trauma. Neck radiographs,bronchoscopy, and CT also may be necessary depending on nature andextent of injury.

Airway Suctioning and Passing of Feeding Tubes

Overaggressive suctioning of airway and repeatedpassage of feeding tubes can cause laryngeal injury and hoarse cryin newborn or young infant.

Foreign Body

Foreignbody located in larynx usually presents with acute onset of chokingand stridor. Impacted foreign body involving larynx can cause hoarseness.

Radiographs of larynx and flexiblelaryngoscopy are usually diagnostic.

Vocal Cord Paralysis

Vagus nerve, by means of recurrent laryngealnerve, helps control vocal cord movement. Any lesion that affectsthese nerves may cause paralysis of 1 or both vocal cords with varyingdegrees of hoarseness and stridor. See Chap. 63, Stertor, Stridor, and Airway Obstruction.

Gastroesophageal Reflux

Moderate-to-severegastroesophageal reflux may cause hoarseness.

Useful investigations include esophagealpH probe, upper GI series, laryngoscopy, and esophagoscopy. See Chap. 55, Regurgitation and Vomiting.

Neoplasm

Benign Tumors

Laryngealpapilloma is most common laryngeal tumor in children. Irregularnodular masses can occur on vocal cords, in pharynx, or below cordsin trachea.

Laryngeal hemangioma is usually locatedin subglottic area and is often associated with cutaneous hemangiomas.

Other laryngeal tumors include lymphangioma,neurofibroma, hamartoma, and granuloma (Wegener granulomatosis).

All these tumors can cause hoarseness,cough, and inspiratory stridor.

Laryngoscopy and bronchoscopy may visualizethe tumors.

Except for hemangiomas, which can usuallybe recognized clinically, histologic diagnosis is definitive.

Malignant Tumors

Malignanttumors of larynx are rare but include squamous cell carcinoma andrhabdomyosarcoma.

Neck radiography, laryngoscopy, bronchoscopy,and CT help define location and extent of tumor.

Histologic diagnosis is definitive.

Diagnostic Approach

In assessmentof children with hoarseness, history and physical exam are diagnostic, especiallywith viral laryngitis, croup, and vocal abuse.

If hoarseness is persistent, progressive,or associated with history of trauma or stridor, neck radiographyand laryngoscopy should be performed.

Combination of neck radiography, laryngoscopy,bronchoscopy, and CT may be used to locate and define extent ofneoplastic lesions.

References

1. Friedberg J. Hoarseness. In: BluestoneCD, et al., eds. Pediatric otolaryngology, 3rd ed. Philadelphia:WB Saunders, 1996:1253–1260.
2. Kenna MA. Hoarseness. Pediatr Rev 1995;16:69–72.
3. Putnam PE, Orenstein SR. Hoarseness in a child withgastroesophageal reflux. Acta Paediatr 1992;81:635–636.
4. Myer CM III, Cotton RT. A practical approach to pediatricotolaryngology. Chicago: Year Book Medical, 1988.
5. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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