Hoarseness in Children

Background

• Hoarseness is a change in voice quality, such as raspy, breathy, strained, fatigued, rough, tremulous, or weak voice, as reported by the patient.
• The reported prevalence of hoarseness in children is 4%-23% (highest in boys aged 8-14 years) with the actual prevalence likely higher as most may not seek treatment, especially if transient.
• Risk factors include vocal fold abuse, prematurity, surgical procedures to the head and neck region, and prenatal exposure to condylomata acuminata.
• The differential diagnosis of hoarseness may be divided into inflammatory, traumatic, congenital, iatrogenic, functional, physical/neoplastic, and other causes.
• The most common causes of hoarseness in children are benign and/or self-limiting conditions.

Evaluation

• The clinical presentation of hoarseness is an atypical cry in infants and a complaint of atypical voice or voice changes in children.
• Obtain a complete history including medications as well as past medical and social histories.
• Perform a thorough physical exam focusing on the nose, throat, and neck exams.
• Red flags identified on history or physical exam should prompt immediate referral to an otolaryngologist (ENT) for further evaluation and include:
  • recent endotracheal intubation
  • recent surgery to head, neck, or chest
  • presence of neck mass
  • respiratory distress or stridor
  • dysphagia
  • failure to thrive
  • recurrent chest infections
• Perform laryngoscopy if:
  • acute hoarseness with red flag symptoms
  • hoarse cry in neonate, especially if premature or having cardiothoracic or neck surgery
  • hoarseness does not resolve or improve in 4 weeks
• Consider stroboscopy to visualize the larynx if a diagnosis cannot be made with laryngoscopy.
• Consider other testing based on a suspected underlying cause including x-ray, magnetic resonance imaging, computed tomography, or ultrasound.

Management

• The successful management of hoarseness depends on identifying and managing the underlying cause.
• A multidisciplinary approach may be needed to assess and manage hoarseness including the pediatrician, pediatric otolaryngologist, and speech and language pathologist.
• Manage acute hoarseness without red flag symptoms conservatively without further evaluation for up to 4 weeks since most cases are due to benign causes and resolve spontaneously.
• The initial management of hoarseness is conservative and should include education on behavioral strategies to promote vocal hygiene and decrease the risk of dysphonia (antibiotics, corticosteroids, and anti-reflux medications should not be routinely prescribed).
• Refer to voice therapy with a speech language pathologist that specializes in pediatric voice to manage causes of persistent dysphonia that are likely to respond to therapy.
• Consider surgery and other targeted interventions when hoarseness is nonresponsive to conservative management or if there is a suspected or confirmed congenital or acquired anomaly.
• Specific surgical procedures and other interventions for hoarseness should be based on the underlying cause.
• Long-term follow-up and continued care is needed to ensure continued compliance with treatment including behavioral changes needed to maintain vocal hygiene.