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Original Article Hoarseness of voice in the pediatric age group: Our experiences
at an Indian teaching hospital

Article · February 2019

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 Original Article
Hoarseness of voice in the pediatric age group: Our experiences at an Indian
teaching hospital
Santosh Kumar Swain1, Ishwar Chandra Behera2, Loknath Sahoo3
From 1Professor, 3Senior Resident, Department of Otorhinolaryngology, IMS and SUM Hospital, 2Professor, Department of Community Medicine, IMS
and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
Correspondence to: Dr. Santosh Kumar Swain, Department of Otorhinolaryngology, IMS and SUM Hospital, Bhubaneswar, Odisha,
India. E-mail: santoshvoltaire@yahoo.co.in
Received - 18 January 2019 Initial Review - 05 February 2019 Accepted - 14 February 2019

ABSTRACT
Background: Hoarseness of the voice or dysphonia is a commonly encountered vocal symptom among children. The etiological
profiles of dysphonia among children are variable, and laryngoscopic examination is required for identification of the lesions.
Objective: The objective of the study was to study the etiology, clinical presentations, and diagnosis of the hoarseness of voice
among children. Materials and Methods: The children aged from 3 to 16 years presenting with dysphonia/hoarseness, were
included in this study from October 2015 to September 2018. All the 132 children presented with hoarseness of voice were
subjected to video laryngoscopy for voice assessment. Results: The majority of this study was male children (59.09%). Vocal
fold nodules (36.36%) were the major cause for dysphonia. Other attributing causes include vocal fold polyp, vocal fold cyst,
laryngopharyngeal reflux, hemorrhagic vocal fold polyp, laryngeal papilloma, vocal fold sulcus, and vocal fold paralysis. Voice
abuse was an important cause for dysphonia and history of vocal abuse was reported among 61 children (46.21%). The duration
of hoarseness ranged from 1 month to 2 years with a mean duration of 3.63±2.31 months. The larynx was examined by laryngeal
mirror alone in 23 children (17.42%), fiber-optic laryngoscopy in 88 children (66.66%), and direct laryngoscopy under general
anesthesia in 21 cases (15.90%). Voice therapy was done in all children along with vocal hygiene care and micro-laryngeal surgery
in 64 cases. Conclusion: Pediatric dysphonia is a common cause for referral to pediatric otolaryngologists and management
sometimes variable. Flexible nasopharyngolaryngoscopy is suitable for making an accurate diagnosis.

Key words: Dysphonia, Hoarseness of voice, Pediatric age, Vocal fold

C
ommunication or speech of children plays a greater stenosis, malignant lesions, polyp, cysts and nodules, allergic or
role in everyday life. Dysphonia and hoarseness are the infectious laryngitis and laryngitis due to gastroesophageal reflux
terminology used for altered voice quality. Dysphonia are other common causes for hoarseness of voice in children [5].
is commonly encountered as a clinical problem in pediatric Endolaryngeal microlaryngoscopic excision by minimal stripping
otolaryngology practice. Hoarseness or dysphonia is around or CO2 laser is helpful for vocal fold lesions such as nodules
6–9% of all childhood voice problems [1]. Pediatric dysphonia and polyps. The variable causes and its effects on the social,
represents a broad-spectrum disorder ranging from hoarseness educational, and emotional part of life prompted us to carry out
to inability to communicate. Hoarseness (often seen in all age such study.
groups) or dysphonia is a disorder characterized by the altered
quality of voice, loudness, pitch or vocal effort which reduces the MATERIALS AND METHODS
voice quality so impairs the communication [2]. The incidence
of hoarse voice in the school-going children was reported as This was a prospective study where the vocal symptoms were
2–23% [3]. Dysphonia has a negative effect on the health of the analyzed along with laryngoscopic findings of the dysphonic
child, communication, social and educational development, self- children between the age group of 3 and 16 years, at a tertiary
image, and self-esteem. care teaching hospital, from October 2015 to September 2018.
The etiologies of pediatric dysphonia are classified into After the Ethical Committee Approval and getting the consent
infectious, inflammatory, traumatic, iatrogenic, congenital, from the respective parents, we included a total of 132 children.
and functional [4]. The functional causes for voice changes All the pediatric patients presenting with hoarseness of voice
in children are emotional or psychological problems such as were included in this study. Exclusion criteria were a history of
personality disorders, adjustment problems, or anxiety. While previous laryngeal surgery, history of radiotherapy of head and
the organic causes are the laryngeal papilloma, laryngeal web, neck region and child not cooperative for examination. Children

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Swain et al. Hoarseness of voice in the pediatric age group

presenting with stridor or dyspnea, acute hoarseness during in early stages. Early stages of vocal fold nodules and polyps were
upper airway infections, genetic syndromes with craniofacial treated conservatively along with speech therapy. Microlaryngeal
malformations, were also excluded from this study. surgery was performed among 29 cases of vocal fold nodules,
The predominant presenting symptoms of the children were 12 cases of vocal fold polyp, 10 cases of vocal fold cysts, 7 cases of
hoarseness of voice. The parents of the children answered the hemorrhagic vocal fold cysts, and 6 cases of laryngeal papilloma.
questionnaire such as age, gender, vocal symptom, history of Voice therapy was done by speech and language therapist in all
voice abuse, nasal symptoms, and gastroesophageal reflux cases along with vocal hygiene care. A case of pediatric glottic
symptoms. All the children with dysphonia had underwent a carcinoma was sent for radiotherapy, and a case of spasmodic
careful and detailed history, general and physical examination, dysphonia was treated with Botulinum toxin injection.
and systemic examinations such as ear, nose, and throat. All
the children presented with hoarseness had undergone proper DISCUSSION
clinical assessment, investigations, and treatment. All the
selected children were examined by the video laryngoscopy for Hoarseness of voice is a common clinical symptom seen among
examination of the larynx. Investigations such as routine blood children of all age groups. The prevalence of hoarseness in the
tests, sputum for acid-fast bacilli, urine microscopy, and imaging children of age group between 8 and 14 years varies from 3.9%
(X-ray chest, X-ray paranasal sinuses, and X-ray neck-lateral to 23.4% [2]. Dysphonia has a negative impact on effective
view) were done in all cases. All the children underwent speech communication, general health, educational development, self-
therapy after proper medical and surgical treatment. image, self-esteem, and participating in a social environment.
Parents of the children and peers often judge the dysphonia
RESULTS among children more negatively than other child of healthy
voices [6]. The characteristic head and neck anatomy in children
There were a total of 132 children with 78 male (59.09%) and has an impact on voice production and dysphonia. The newborn
54 female (40.90%) presented with hoarseness of voice during the baby has a small mandible, small mouth, large head, and more
study period, with a male to female ratio of 1.4:1. The youngest
patient in our study was 3-year-old boy and oldest was 16 years
old with the mean age of 10.34 year. Among the children above
11 years, there were more girls than the boys (Table 1).
History of vocal abuse was reported among 61 children (46.21%).
The duration of hoarseness ranged from 1 month to 2 years with a mean
duration 3.63±2.31 months. The larynx was examined by laryngeal
mirror alone in 23 children (17.42%), fiber-optic laryngoscopy in 88
children (66.66%), and direct laryngoscopy under general anesthesia
in 21 cases (15.90%). Vocal fold nodules (Fig. 1) were found in 48
children (36.36%), vocal fold polyp (Fig. 2) in 23 cases (17.42%),
and vocal fold cyst (Fig. 3) in 19 cases (14.39%).
Further, laryngopharyngeal reflux was found in 18 cases
(13.63%), hemorrhagic vocal fold polyp (Fig. 4) in 7 children
(5.30%), laryngeal papilloma (Fig. 5) in 6 cases (4.54%), vocal
fold sulcus in 5 cases (3.78%), vocal fold paralysis in 4 children Figure 1: Vocal fold nodules
(3.03%), laryngeal carcinoma in one case (0.75%), and spasmodic
dysphonia in 1 case (0.75%) (Table 2).
Seven children (5.30%) had a history of sudden phonotrauma
followed by the development of large hemorrhagic vocal fold cyst.
Out of 48 children with vocal fold nodules, 19 cases presented
with an early stage of nodules. Out of 23 cases of vocal fold polyp,
11 cases were in early stages whereas 9 cases of vocal fold cysts were

Table 1: Correlation between age and sex of children with

hoarseness of voice
Age 3–6 years 6–10 years 11–16 years
n (%) n (%) n (%)
Sex
Girl 16 (12.12) 22 (16.66) 27 (20.45)
Boy 21 (15.90) 26 (19.69) 20 (15.15)
Figure 2: Left vocal fold polyp

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Swain et al. Hoarseness of voice in the pediatric age group

Table 2: Distribution of vocal fold pathologies

Vocal fold pathologies Number of children (%)
Vocal fold nodule 48 (36.36)
Vocal fold polyp 23 (17.42)
Vocal fold cyst 19 (14.39)
Laryngopharyngeal reflux 18 (13.63)
Vocal fold hemorrhagic polyp 7 (5.30)
Laryngeal papilloma 6 (4.54)
Vocal fold sulcus 5 (3.78)
Vocal cord paralysis 4 (3.03)
Glottic carcinoma 1 (0.75)
Spasmodic dysphonia 1 (0.75)

Figure 3: Left vocal fold cyst

The higher position of the larynx makes a tighter oral seal and
helps the infants to breathe while feeding. The connective tissue
layers of the lamina propria in vocal folds are not well delineated
or not well defined and vocal ligament not fully developed in
children. In growing infant, the functions of the larynx evolve
from primary airway protection to complex phonatory function
along with airway protection.
According to Hirano’s cover-body theory of the vocal fold
vibration, the epithelium and superficial layer of the lamina
propria forms the “cover,” the vocalis muscle forms the body,
and the intermediate and deep layers of the lamina propria
constitute the vocal ligament, are the “transition” layer [7]. The
cover layer is often involved in the mucosal wave vibration of
the vocal folds. The basement membrane zone (BMZ) consists
Figure 4: Right vocal fold hemorrhagic polyp
of extracellular matrix which attaches and secures the overlying
epithelium of the vocal fold. The BMZ is divided into two layers,
the superficial lamina lucida and deep lamina densa which are
joined by anchoring filaments consisting of collagen type IV and
fibronectin [8].
Hemorrhagic polyps in the vocal fold are usually due to
phonotrauma such as voice abuse or misuse. Trauma to larynx
either external (blunt) or internal as in endotracheal intubation or
prolonged nasogastric tube injury, cause injury to vocal fold and
lead to change in voice or dysphonia. Vocal fold nodules are a
common cause of dysphonia during childhood. Vocal fold nodules
are seen in 40% of the cases suffering from voice disturbances [9].
In this study, vocal fold nodules are seen in 36.36% cases. Vocal
fold nodules have a strong relationship with allergic rhinitis;
upper respiratory tract infections and gastroesophageal reflux are
Figure 5: Papillomas over both vocal folds the major predisposing factors [10]. Laryngopharyngeal reflux
was seen in 18 children (13.63%). Children with chromosomal
fat pads at the cheeks and tongue filling the entire oral cavity. All defects cause dysphonia as in case of cri du chat syndrome.
these anatomical characteristics have an impact on the speech of In the pediatric age group, the behaviors of the male child are
the child. more impulsive and aggressive than a female child and are allied
The larynx of the child is present high in the neck in relation to anxiety, spirit of leadership, and excessive hyperactivity. These
vertebra of the neck and cricoid cartilage at the fourth cervical profiles of a male child directly reflect in phonatory mechanisms,
vertebra (C4), in comparison to C6–C7 vertebra in adults. There is leading to vocal abuse [11]. As age increases in childhood, the
also a closer relationship between the epiglottis and soft palate and larynx undergoes structural changes due to masculine hormones
a shorter length vocal tract than adults. The laryngeal cartilages in adolescence, leading to enlargement of laryngeal dimension. In
and vocal folds of the larynx changes as the child grow or mature. male adolescent, the new glottic configuration is characterized by

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Swain et al. Hoarseness of voice in the pediatric age group

longer vocal folds along with the acute angle of thyroid cartilage where vocal fold shows a furrow on the medial edge. The
approximately 90°. During the adolescent period of a male child, common symptom of vocal fold sulcus is a hoarse and breathy
symptoms of dysphonia tend to decrease and vocal nodules voice. Persistent pediatric dysphonia is sometimes associated
begin an involution process. Such types of changes are not seen with airway obstruction, dysphasia or pain, which should be
in adolescent girls. In adolescent girls, the vocal folds elongate investigated promptly.
3–4 mm whereas in boys, it increases by 1 cm [12]. Children in Endoscopy with trans-nasal flexible scope is often useful in all
a family with siblings are often prone to dysphonia [13]. One the cases of pediatric dysphonia for identifying the morphodynamic
study showed that 65% of the children suffering from dysphonia alterations. Stroboscopy is carried out only in the older age group
belonged to large families, i.e. >2 children, 30% of the children of children. Video laryngoscopy examination gives a better view
had a family history of dysphonia out of which 57% were male of the larynx and particularly vocal fold as compared to indirect
child [14]. laryngoscopy. Video laryngoscopy examination gives large
Outcomes of this study suggest that noisy surroundings need magnification, better angle of visualization, better illumination,
excessive demand for loud talking which makes the risk for and resolution. Computed tomography (CT) and magnetic
formation of vocal nodules and dysphonia [14]. Phonotrauma resonance imaging are usually advised for any neoplastic
in a noisy environment is an important risk factor for causing assessment in the larynx. Any laryngeal stenosis is assessed by CT
dysphonia among children [15]. The most common etiology for scan. Virtual endoscopy has been advised and nowadays used as a
hoarseness of voice among children is vocal fold nodules, which replacement for classical laryngeal endoscopy during follow-up.
have been seen in 38–78% of the pediatric patients evaluated for It is often helpful for assessing the topography of stenosis and
dysphonia [1]. Other vocal fold lesions such as localized edema tumors. Diagnostic biopsy of the tumor or papillomatosis lesions
and irregular surface at the junction of the anterior and middle is done to find out the pathological diagnosis. The differential
third of the vocal fold are found in 13.3% children of those diagnosis of pediatric dysphonia is broad. A thorough and careful
evaluated for dysphonia [12]. evaluation is essential for the exact diagnosis of the etiology.
In this study, vocal abuse was a major cause for dysphonia The treatments of pediatric dysphonia need individual
among children (46.21%). There were equivalent results basis. The therapeutic options available are counseling, voice
documented by other studies such as Connelly et al. (45.2%) [16] re-education, medical treatment, psychotherapy, and surgical
and Angelillo et al. (90.3%) [15]. Vocal fold polyps occur mainly intervention. CO2 laser is quite effective for treatment of vocal
among children those use their voices very intensively and fold polyp and nodules. It will completely excise the polyp
develop at the site of maximum muscular and aerodynamic forces without injuring adjacent tissue and bleeding. A combination of
exerted during phonation, and it is considered as the squeal of vocal hygiene and CO2 laser is highly effective treatment for vocal
phonotrauma. In this study, vocal fold polyp was seen in 17.42% fold lesions such as polyp and nodules. In the case of spasmodic
cases. The metabolic or endocrinal causes may lead to dysphonia dysphonia, there is focal dystonia affecting the laryngeal muscles
in children by metabolic errors which cause disruption of normal during speech. It may be adductor spasmodic dysphonia (common)
enzymatic activity and cause abnormal infiltration or faulty or abductor one (rare) [18]. In this study, one child presented with
muscle and nerve function. adductor spasmodic dysphonia those often presenting with voice
In Urbach-Wiethe’s disease or mucopolysaccharidosis, breaks and was treated with Botulinum toxin. In our study, one
dysphonia occurs by laryngeal involvement. In a hypothyroid child, case of pediatric glottic carcinoma was diagnosed in the early
there is generalized hypotonia and myxoedematous infiltrations in stage which was treated by radiation therapy.
the vocal folds. Extrinsic administration or abnormal secretion of
testosterone or estrogen interfere with normal laryngeal function CONCLUSION
and often lead to dysphonia. Recurrent respiratory papillomatosis
is common during childhood. It is common in a first born child, Hoarseness of voice among the children is not an uncommon
young primigravida mothers and low socioeconomic groups [12]. clinical entity. Pediatric dysphonia accounts for a good number
In this study, laryngeal papilloma was seen in 6 cases (4.54%). of referrals. There are variations in the protocol of management
Psychogenic causes such as emotional disturbances, psychic among different centers. A structures protocol is needed for the
trauma, and disturbed parent-child relationship are sometimes diagnosis and managing the pediatric dysphonia.
counts as the cause for dysphonia among children. Psychogenic
causes such as family conflict and exacerbated expectations REFERENCES
are a major cause for dysphonia in children [17]. In the case of
psychogenic dysphonia, vocal strain is usually not seen, and vocal 1. Bisetti MS, Segala F, Zappia F, Albera R, Ottaviani F, Schindler A, et al.
Non-invasive assessment of benign vocal folds lesions in children by means
folds are normal. The cough sounds and laugh of the children are of ultrasonography. Int J Pediatr Otorhinolaryngol 2009;73:1160-2.
usually normal whereas, disturbed mutation often associated with 2. Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES,
psychogenic dysphonia. Gillespie MB, et al. Clinical practice guideline: Hoarseness (dysphonia).
Otolaryngol Head Neck Surg 2009;141:S1-S31.
Congenital lesions of the pediatric larynx are webs and cysts
3. Speyer R. Effects of voice therapy: A systematic review. J Voice
whereas neoplastic lesions of the vocal folds help for visualization 2008;22:565-80.
of the larynx. One of the congenital etiology is vocal fold sulcus 4. Martins RH, Ribeiro CB, de Mello BM, Branco A, Tavanes EL. Dysphonia

Vol 6 | Issue 2 | February 2019 Indian J Child Health  77

Swain et al. Hoarseness of voice in the pediatric age group

in children. J Voice 2012;5:674-20. 2006;20:623-30.

5. Swain SK, Panda M, Patro N, Sahu MC. A rare cause of hoarsness of voice: 14. Angelillo N, Di Costanzo B, Angelillo M, Costa G, Barillari MR, Barillari U,
Lipoidproteinosis of the larynx. Int J Phonosurg Laryngol 2014;4:23-6. et al. Epidemiological study on vocal disorders in paediatric age. J Prev Med
6. Connor NP, Cohen SB, Theis SM, Thibeault SL, Heatley DG, Bless DM, Hyg 2008;49:1-5.
et al. Attitudes of children with dysphonia. J Voice 2008;22:197-209. 15. Tavares EL, Brasolotto A, Santana MF, Padovan CA, Martins RH.
7. Hirano M, Kakita Y. Cover-body theory of vocal fold vibration. In: Epidemiological study of dysphonia in 4-12 year-old children. Braz J
Daniloff RG, editor. Speech Science. San Diego, Calif: College Hill Press; Otorhinolaryngol 2011;77:736-46.
1985. p. 1-46. 16. Connelly A, Clement WA, Kubba H. Management of dysphonia in children.
8. Gray SD, Pignatari SS, Harding P. Morphologic ultrastructure of anchoring J Laryngol Otol 2009;123:642-7.
fibers in normal vocal fold basement membrane zone. J Voice 1994;8:48-52. 17. Hirschberg J. La disfonia nella prima e nella seconda infanzia. In: Foniatria
9. Shah RK, Feldman HA, Nuss RC. A grading scale for pediatric VFNs. e Logopedia Oggi. Torino: Edizioni Omega; 1985. p. 129-42.
Otolaryngol Head Neck Surg 2007;136:193-7. 18. Ludlow CL. Treatment for spasmodic dysphonia: Limitations of current
10. Nardone HC, Recko T, Huang L, Nuss R. A retrospective review of approaches. Curr Opin Otolaryngol Head Neck Surg 2009;17:160-5.
theprogression of pediatric VFNs. JAMA Otolaryngol Head Neck Surg
2014;140:233-6. Funding: None; Conflict of Interest: None Stated.
11. Kiliç MA, Okur E, Yildirim I, Güzelsoy S. The prevalence of vocal
fold nodules in school age children. Int J Pediatr Otorhinolaryngol How to cite this article: Swain SK, Behera IC, Sahoo L. Hoarseness of voice
2004;68:409-12. in pediatric age group: Our experiences at an Indian teaching hospital.Indian
12. Pontes P, Kyrillos L, Behlau M, De Biase N, Pontes A. Vocal nodules and J Child Health. 2019; 6(2):74-78.
laryngeal morphology. J Voice 2002;16:408-14.
13. Carding PN, Roulstone S, Northstone K, ALSPAC Study Team. The Doi: 10.32677/IJCH.2019.v06.i02.006
prevalence of childhood dysphonia: A cross-sectional study. J Voice

Vol 6 | Issue 2 | February 2019 Indian J Child Health  78

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