My Child’s Voice

Here we discuss a number of common conditions related to voice:

• Hoarseness
• Voice Problems (Dysphonia)
• Phonotrauma
• Velopharyngeal Insufficiency (VPI) / Nasal Emissions
• Vocal Cord Dysfunction
• Vocal Cord Paralysis (VCP)
• Gastroesophageal Reflux Disease (GERD)
• Recurrent Respiratory Papillomatosis (RRP)

 

ENT for Children may recommend a voice evaluation, speech therapy or other treatments for children or adolescents who suffer from voice and airway problems.  ur voice is something that we often take for granted until there is a problem. Voice problems can affect a child’s social environment and can pose difficulty in school and communicating with others. Voice problems will also impact singing, acting and public speaking. We provide an overview of some of the more common voice problems and terms in children.

Hoarseness

The general term most commonly used for an abnormal clarity of the voice is “hoarseness”, which is also commonly referred to as a “raspy” voice. This describes how the voice sounds. A hoarse voice is a rough or unclear voice and may also limit the function of the voice (termed dysphonia). Generally speaking, the symptoms for hoarseness can be similar to laryngitis.

Hoarseness can occur in anyone and for many different reasons, the most common being from an upper respiratory infection, also known as the common cold.  Other common causes of hoarseness are:

• Vocal cord nodules
• Chronic coughing / throat clearing
• Gastroesophageal reflux
• Environmental allergies and/or post-nasal drainage
• Breathing in irritants in the air (chemicals, second hand smoke, etc)
• Vocal cord polyps
• Vocal cord papillomas
• Vocal cord paralysis
• Prior vocal cord or airway surgery

Whatever the cause, hoarseness occurs because the vibratory pattern of the vocal cords becomes disrupted which results in the voice change or hoarseness. If the hoarseness does not improve after four weeks following the onset, a pediatric ENT specialist with experience in voice problems should examine your child.

Voice Problems (Dysphonia)

Dysphonia describes how the voice functions.  Dysphonia is a general term that describes a voice that is not functioning properly.  This may be from any number of conditions including those listed above under “Hoarseness.” Dysphonia can impact a child’s normal vocal range, limit his/her vocal stamina and decrease the projection (loudness) of the voice.  More severe situations can also cause pain when speaking or breaks in the voice.  Dysphonia is a problem not only for normal communication but also for focused tasks such as singing or public speaking.

The key to treating dysphonia first starts with making a proper diagnosis of the underlying problem.  A thorough history and exam are very important.   Your ENT for Children voice specialist may recommend lifestyle changes, medications, speech therapy or surgery to improve the voice.

Phonotrauma

Voice problems in children may be the result of the child experiencing phonotrauma. Also known as vocal misuse, phonotrauma can cause damage to your child’s vocal cords. Actions like yelling or screaming bring a child’s vocal folds together forcefully which causes the vocal cords to swell and become inflamed.  Generalized overuse of the voice such as prolonged singing or public speaking will also result in phonotrauma.  Phonotrauma that is not corrected or treated can lead to the formation of vocal nodules.  These nodules form as a results of the body attempting to protect the vocal cords by forming calluses on the surface of the vocal cords, similar to calluses that can develop on the fingers from prolonged friction,Vocal Cord Nodules

The most common reason for chronic hoarseness in children is vocal cord nodules. These are abnormal growths or calluses on a child’s vocal cords and may occur if a child engages in the following activities for a prolonged duration:

• Yelling, screaming or crying
• Repetitive clearing of the throat or coughing
• Speaking in a strained voice
• Repetitive lowering and raising the pitch of the voice
• General overuse of the voice such as intense singing or public speaking

Phonotrauma leads to swelling and inflammation on the surface of the vocal cords. If the trauma continues then these swollen areas harden into nodules. These nodules then enlarge as the problem continues. Treatment of vocal nodules involves correcting the condition that caused the nodules to form in the first place.  Speech therapy is also frequently recommended to improve the way your child uses his/her voice. Any coinciding allergies or reflux should also be controlled.

Velopharyngeal Insufficiency (VPI) / Nasal Emissions

VPI (Velopharyngeal insufficiency) is a speech disorder that occurs when your child’s velopharyngeal sphincter does not close properly. This occurs when the roof of the mouth (soft palate) does not completely close and allows air to escape from the nose rather than the mouth during speech.

Several structures need to come together in order to close the nose off from the mouth during speech. The process is also known as velopharyngeal closure which depends on the walls at the side of the throat (lateral pharyngeal walls), the soft palate (velum) and the pharyngeal wall at the back of a child’s throat.

The velopharyngeal sphincter must close to enable a child to pronounce consonants like “p, s, g, b, t and d.” A child who suffers from the condition will end up producing breathy or abnormal sounds while attempting to pronounce the consonants. Children who cannot attain full velopharyngeal closure will still be able to vocalize consonants like “h, w, I, y and r.”

Other symptoms that are indicative of VPI include:
Hypernasality: also known as nasal speech, hypernasality is a common symptom in children who cannot achieve full velopharyngeal closure during speech.

The “n” or “ng” sound can only resonate nasally. Hypernasality causes a child to resonate sounds other than these through the nose. The symptom may be mild or severe depending on the extent of the condition.

Nasal Emissions: a child who suffers from VPI will have trouble vocalizing pressure consonants or consonants that require the child to build air pressure in the mouth to produce normal sounds. Nasal emissions will occur when your child’s condition causes air to escape through the nose instead of the mouth while he/she tries to produce certain sounds.  The child’s speech may sound muffled and may cause your child to produce squeaks, puffs or snorts during speech.

The symptoms that are associated with VPI may cause children to develop speech impairments to compensate for the condition. ENT for Children may assess your child’s speech by conducting an imaging test or by performing a video nasal endoscopy.  This is a short office procedure where a think flexible camera is inserted into the nose to the back.  Your child is then asked to repeat several different words and phrases while the video and audio are recorded for playback.  This allows a direct analysis of how the velopharyngeal muscles are closing or not closing. Treatment of VPI initially starts with focused speech therapy by a pediatric speech therapist experienced in treating VPI.  If speech therapy does not correct the problem, your ENT for Children surgeon will discuss various surgical procedures to help get complete closure of the velopharyngeal sphincter.

Vocal Cord Dysfunction

When your child inhales, the vocal cords open and allow air into the lungs. VCD (Vocal Cord Dysfunction) also known as Paradoxical Vocal Fold Motion occurs when the vocal cords fail to open properly as the child inhales leading to acute episodes of breathing problems.  A child who suffers from VCD will have a narrowing of the airway and thus only be able to breathe in a small amount of air.  This is why the symptoms of VCD are similar to an asthma attack and why this condition can be misdiagnosed for asthma.

Vocal Cord Dysfunction may be triggered by other medical conditions such as brain injury or brain lesions, exercise, gastroesophageal reflux, allergies and postnasal drainage.  In some patients, VCD may also have a psychological component from anxiety, stress or depression.  Those who suffer from the dysfunction may have repeated episodes of labored breathing if they are exposed to irritants like cigarette smoke, perfumes and cold air. Other symptoms that may be indicative of the VCD may include the following:

• Tightness in the chest or throat
• Difficulty inhaling air
• Chronic cough
• Stridor (noisy breathing)
• Feeling of throat closing
• Intermittent shortness of breath

The symptoms may also be the result of other medical conditions. Your ENT for Children specialist will discuss with you these possibilities.  Often, other specialists may be consulted to help treat your child’s problem.

Your pediatric ENT may recommend a fiberoptic office stroboscopy to visualize the motion of the vocal cords.  This may also provide insight into possible triggers and rule out other vocal cord problems..

The treatment of vocal cord dysfunction usually involves targeted therapy with a pediatric speech therapist.  The therapist will help your child to control the VCD symptoms through various breathing and behavioral techniques.  Also identifying specific triggers and either avoiding them or treating them can help decrease the frequency and severity of episodes.  Your pediatric ENT voice specialist will discuss various treatments with you in more detail.

Vocal Cord Paralysis (VCP)

The “V” shaped vocal cords in your child’s larynx, or voice box, open to allow breathing and close to vibrate in order to produce sound and to protect the lungs during swallowing. Vocal Cord Paralysis, also known as vocal fold paralysis, occurs when either one or both vocal fold(s) fail to move appropriately to open and close. Children who suffer from the condition can have trouble with their voice, breathing and swallowing.  These problems all occur because the paralyzed vocal cord is stationary off to the side (paramedian position) and cannot make contact with the non-paralyzed vocal cord.  Vocal cord paralysis can be either congenital or acquired.  There can be several different causes for vocal fold paralysis.  Some of the more common causes are:

• Congenital with no known cause
• Birth trauma from complicated delivery
• Neurologic or brain disorders
• Nerve injury from neck surgery
• Nerve injury from chest or cardiac surgery
• Prolonged intubation

The condition may occur as the following two types:
Bilateral vocal cord paralysis: both the vocal cords become impaired in the paramedian position (while opening and closing) and do not move either way. This condition allows for near normal voice and swallowing but can cause significant breathing problems.

Unilateral vocal cord paralysis: only one of the child’s vocal cords are impaired.  This will usually cause a hoarse, breathy voice and may cause trouble swallowing and breathing.

Of the two, unilateral VCP is more common in children. Since the paralyzed vocal cord does not vibrate with the other it will cause the child to run out of air faster and cause breathing or speech problems. The most common symptoms of VCP include:

• Breathy voice
• Hoarse voice
• Trouble with vocal pitch
• Coughing or choking while drinking liquids
• Running out of breath while speaking
• Inability to speak loudly
• Trouble breathing or noisy breathing

Your ENT for Children will diagnose your child’s condition by performing a flexible laryngoscopy in the office with a thin, flexible video camera. This allows live visualization of the movement of the vocal folds during speaking or crying.

Treatment of vocal cord paralysis varies depending on the cause and if it is unilateral or bilateral.  Other factors in determining the best treatment include how long the paralysis has been present and if the paralysis was from nerve injury.  Nerve injury can heal over time.  Also, it is important to assess your child’s swallowing and breathing since those are the most important functions of the vocal folds.  Your ENT for Children specialist will discuss these tests and treatments with you in more detail once the diagnosis has been made.

If the vocal paralysis has been determined to be permanent, your ENT for Children voice specialist will also discuss effective surgical options to improve your child’s voice, breathing and swallowing.

Gastroesophageal Reflux Disease(GERD)

Voice problems may also occur in children who suffer from GERD (Gastroesophageal Reflux Disease). The condition is common in newborn babies but may remain as the child grows older. The condition occurs when stomach acid and food back up from the stomach into the esophagus or throat.  Symptoms of GERD may include:

• Dysphagia (trouble swallowing)
• Heartburn
• Belching
• Tightness in the throat
• Chronic cough or throat clearing
• Bad breath
• Hoarseness
• Regurgitation of food
• Bitterness or sour taste in the mouth
• Chronic sore throat

Chronic acid reflux can cause certain voice problems; however more commonly acid reflux will worsen voice problems that are already present, such as: vocal nodules, vocal papillomas, laryngomalacia, vocal cord dysfunction, etc.  This is why controlling GERD is important in treating various voice problems.

ENT for Children may perform a flexible laryngoscopy to look for signs of reflux in the tissue of the throat and voice box.  We may also recommend your child see a pediatric GI specialist for further workup or treatment.

Recurrent Respiratory Papillomatosis (RRP)

Respiratory (also known as Laryngeal) Papillomatosis is a rare disease that occurs when benign non-cancerous tumors develop in the respiratory tract, vocal cords or throat. The papillomas are wart-like growths and are the result of a HPV (human papilloma virus) infection. As the wart-like growths enlarge, the child will have progressive worsening of the voice and possible breathing problems if the papillomas block the airway.

Symptoms of Laryngeal Papillomatosis in children and infants may include:

• Hoarse cry / voice
• Stridor (Noisy breathing)
• Chronic coughing or throat clearing

The treatment for laryngeal papilomas is surgical removal to improve the voice and breathing.  This is performed in a minimally invasive manner with a laryngoscopy and bronchoscopy through the mouth under anesthesia.  The difficult aspect of this disease is that the papillomas will often regrow and require repeated surgery, which can increase the risk of scarring in the voice box.  There are additional investigational medications that may help slow the growth of the papillomas that your ENT for Children specialist will discuss with you.