"When you catch a colt, you get a little horse." - Anonymous.

Hoarseness, or more broadly termed voice disorder, can affect children for a myriad of reasons. Common viral croup and laryngitis are easy to both recognize and deal with. Hoarseness or voice disturbance arising under other circumstances can be puzzling; causes range from benign to serious. Because the causes of hoarseness can be so varied, I will break them down into types and attempt to present the most common in some semblance of order. This is more detail than you probably need, but this is a good review for me as well. The take home lesson for parents is simply that there are many causes of hoarseness in children, and while almost all cases of hoarseness are benign and self-limited, there are sufficient other, more unusual causes and situations that might make you consider consultation with your child's doctor (always a good idea when in doubt).

Congenital causes

  • The most common cause of noisy or hoarse breathing in newborns is laryngomalacia, discussed elsewhere.
  • Laryngeal webs are webs of tissue within the larynx which partially block the air channel. 75% of the time they lie between the vocal folds, but they can occur above or below the folds.
  • Laryngeal cysts are mucus or fluid-filled cysts that arise in the larynx, often associated with a history of intubation. Laryngocoeles are air-filled rather than fluid-filled.
  • Genetic causes of hoarseness or stridor which are manifested at birth include Cri du chat syndrome, and Down syndrome.
  • Vocal fold (vocal cord) paralysis can be present at birth, either of one or both vocal folds. Tumors within the chest cavity of the heart (mediastinum), certain heart abnormalities, or birth trauma can cause damage to the laryngeal nerve that supplies the vocal folds. This is by rather strange reason of anatomy. Part of the laryngeal nerve courses down into the chest, loops around the aorta, and courses back up to the larynx. Go figure.

Infectious causes

  • Most infection-caused hoarseness is due to viral infection. Most common viruses are rhinovirus (common cold virus), adenovirus, influenza virus, and parainfluenza virus.
  • Bacterial infection of the larynx region can occur. Bacterial epiglottitis (supraglottitis) was once a common and potentially fatal infection; the HiB vaccination has almost eliminated it. While Hemophilus influenzae type B (HiB) epiglottitis does not occur any more, other bacteria such as Staphylococcus aureus and Streptococcus pneumoniae still cause rare cases of bacterial epiglottitis.
  • Candida (yeast) infection of the mouth and throat region can sometimes be severe enough to cause hoarseness in healthy children, but this rare complication is usually seen in immunosuppressed children (chemotherapy, HiV, or immune deficiency syndromes).

Inflammatory causes

  • Vocal nodules ("screamer's nodules", "singers nodes") are the most common cause of chronic childhood hoarseness, accounting for three fourths of all such cases. They are due to chronic vocal abuse. Vocal nodules usually come in pairs that arise symmetrically from each vocal fold. These nodules usually do not require any specific treatment, because they go away after puberty. Speech therapy to modify the abusive vocal patterns may be helpful.
  • Vocal polyps are benign fleshy growths on the vocal folds that require surgical removal. They are usually found only on one vocal fold.
  • Allergic rhinitis (hay fever) may cause persistent hoarseness if there is chronic postnasal drainage. Nasal steroids and antihistamines are helpful to control the underlying aggravating condition.
  • Gastroesophageal reflux disease can cause inflammation of the larynx, swelling of the vocal folds, and hoarseness. The irritant effect of stomach acid on the vocal tissues is thought to aggravate the formation of vocal nodules as well.
  • Juvenile rheumatoid arthritis may cause hoarseness by affecting the larynx directly.

Benign tumors

  • Papillomas are wartlike benign tumors that can occur in the respiratory tract. They are caused by the human papilloma virus (HPV). Mothers may harbor the virus in lesions called condylomas on the vulva. The infant acquires this infection at birth either through contamination of the amniotic fluid before delivery or during vaginal delivery. These growths can enlarge rapidly and cause respiratory difficulty. Treatment is by carbon dioxide laser therapy.
  • Hemangiomas, benign blood vessel tumors, may occur in the area of the airway and cause either hoarseness, or more commonly stridor.
  • Lymphangiomas (cystic hygromas) are lymph vessel tumors that parallel hemangiomas. They often occur in the head and neck region, and can impinge on the airway causing stridor or hoarseness.

Malignant tumors

  • Can also very rarely infiltrate the laryngeal tissue and cause hoarseness.

Traumatic causes

  • Endotracheal intubation for surgery or resuscitation can cause subsequent hoarseness.
  • Traumatic fracture of the larynx is rare in young children, but trauma can cause hoarseness.
  • Nerve injury to the laryngeal nerve can happen as a complication of cardiac surgery (patent ductus arteriosus surgery, for example) or surgery on the neck or thyroid gland.
  • Foreign bodies ingested by young children can lodge in the larynx and cause hoarseness and difficulty breathing. Hoarseness after a choking episode should make parents and physicians very suspicious of what might be lurking around the larynx.

Metabolic causes

  • Hypothyroidism (low thyroid hormone levels) can cause marked hoarseness.
  • Testosterone producing tumors in females can cause vocal fold thickening and a deepening voice.

Miscellaneous causes

  • Hearing loss can cause hoarseness based on the child's inability to modulate the voice with resultant vocal straining.
  • Psychological problems are a rare cause of pseudo-hoarseness. These children lose the ability to speak, but can still whisper.

These are all the causes of hoarseness it is reasonable to include. Perhaps this compendium will be helpful to someone. Again, the bottom line is that common causes are common, and rare causes are rare; but rare things do happen. Hoarseness, especially a newly developed condition that does not seem to fit the usual pattern of hoarseness from a cold or croup or that lasts longer than expected, should be discussed with your child's physician.

This article is based on the excellent review article of Requena, Derkay, and Darrow, Journal of Respiratory Diseases for Pediatricians 2000, 2:103-110.

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