Why Does My Child Sound Hoarse? Understanding Laryngitis

The larynx is the voice box. Laryngitis is an inflammation of the larynx. It can be acute or chronic, lasting more than three weeks.

Laryngitis is often a result of an acute viral infection, which is self-limiting and lasts for up to a week. There are infectious and non-infectious causes of laryngitis. The distinction between the two may overlap. Hoarseness is the term used to describe any change in voice quality. It can include vocal tremor, weakness, fatigue, altered pitch, breathiness, or strained voice qualities.

Diagnosis of laryngitis relies on the voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life. There are significant disparities in the presenting symptoms, diagnostic testing, and medical treatment between adults and children.

This article will highlight some issues with acute laryngitis and briefly delve into the other special issues clinicians may face with children whose voice, breathing or swallowing remains impaired even after an upper respiratory infection dissipates or does not seem to be the problem in the first place.

Why does my child sound hoarse?

Many children can become hoarse either from an acute respiratory infection or voice abuse. Once the child is better from the infection, their voice improves.

Alternatively, avoiding yelling or screaming can result in reduced vocal strain. Asking a child to rest their voice by writing notes only or simple yes or no answers can be an arduous task, but it may be the answer.

Children who suffer from asthma or are constantly clearing their throat from nasal or sinus problems can also be at risk of developing a raspy voice.

Many home remedies are beneficial including:

• Moist air using a humidifier
• Drinking plenty of fluids to avoid dehydration
• Moistening the throat with lozenges or rinsing with salt water
• Avoiding decongestants or antihistamines, which can dry the mouth and throat
• Avoiding whispering, which can actually worsen the hoarseness and cause more voice strain

What changes happen to the voicebox to produce hoarseness?

As you would imagine, the differences in size between the female and male voicebox are significant. The difference between an adult and a child’s vocal cords are even more dramatic. It does not take much for a child’s voice to become impaired since their vocal cords can be exceedingly small.

When we refer to the vocal cords, we are actually referring to what is known as the true vocal folds. There are also a paired set of false vocal cords or vestibular folds. The true vocal folds are lower in the throat, and they produce sound. The false vocal cords are higher in the throat, and they are responsible for the resonance of our voice. The true and false vocal cords are separated by a space called the rima glottidis.

In acute laryngitis, there is an inflammatory response of the lining or mucosa of the true vocal folds. There are fine layers of membranous lining (like skin) which cover the vocal fold muscles (vocalis).

The true vocal folds become swollen (edematous), and vibration is affected. A common occurrence is for fluid or edema to fill the space between the vocal fold lining and the muscle, and this is called Reinke’s edema. Reinke’s edema can cause a lowering of the voice quality. It may subside after the infection is gone, or it may not and require voice rest and therapy. It may also require further investigation.

What is the best way to diagnose laryngitis?

The cause is determined by a healthcare provider by taking an extensive history and performing a thorough physical examination. The obvious reasons can be ascertained quickly such as an upper respiratory infection, asthma, or voice abuse.

There are no necessary laboratory tests. Antibiotic treatment or steroids are necessary for cases of bacterial infection. The best way to diagnose laryngitis or hoarseness may be by taking a direct look at the vocal cords. This process is somewhat easier in adults, but most children, especially older children, can tolerate the process of looking.

An ear nose and throat (ENT) specialist may attempt to use a light and a curved dental mirror to look at the vocal cords. This may seem old fashioned, but it still may be a good method. In children, this procedure may seem daunting, but often the vocal cords are smaller than adults and closer to the back of the child’s tongue so it can be not only achievable, but fairly easy.

Another method is by flexible fiberoptic laryngoscopy. The technology for this equipment has improved dramatically and most younger ENT physicians prefer this method. This is performed with a fiberoptic light that is attached to a powerful light source and either an eyepiece or a camera for visualization. The fiberoptic laryngoscope is passed through the nose and into the throat after the nose is anesthetized with topical medication. This procedure is surprisingly well-tolerated in most cases.

The fiberoptic laryngoscope is smaller for pediatric patients than that used on adults. And, in rare instances, the smaller laryngoscope can be used in small children or infants directly through the mouth without any anesthesia or touching the sides of the mouth or throat. This method provides a lot of valuable information without having to place the child asleep under anesthesia.

By observing the true vocal cords directly, the ENT specialist can determine if the vocal cords are swollen, red, infected, have an unusual coating, if there are any abnormalities such as polyps or nodules, and most importantly, if the vocal cords are moving properly.

What is vocal cord paralysis and what does it mean in children?

The majority of children who have laryngitis do not have vocal cord paralysis, or one vocal cord not moving. Both vocal cords not moving is beyond the scope of this article.

The reason to discuss unilateral vocal cord paralysis in children is because it highlights the differences between diagnosis of vocal dysfunction in adults and children. And it can explain why it is often necessary to have a child undergo a look at their vocal cords to make sure there is not a paralysis.

In children with laryngitis, there can be persistent hoarseness even after the child’s infection has cleared. The top symptoms to look out for are altered quality of the voice (breathiness), gastroesophageal reflux (GERD), feeding difficulty, and choking, particularly in infants.

Most cases of vocal cord paralysis resolve with the proper diagnosis and treatment in children. This description is not meant to strike fear into parents, but rather to emphasize that all children who have persistent hoarseness deserve to be evaluated.

For example, treating the child for GERD may simultaneously solve the problems of hoarseness, feeding, and growth.