Diagnosis of Pediatric Voice Disorders

Key Glossary Terms

Stridor
Noisy breathing

Larynx
Highly specialized structure atop the windpipe responsible for sound production, air passage during breathing and protecting the airway during swallowing

Glossary

Typically, hoarseness in children is present for a long period of time. Often, family members do not notice the rough quality of the child's voice until someone like a teacher, friend, or doctor points it out to them. Once this hoarseness is identified, often the family cannot remember a time when the child did not sound that way.

• Voice quality varies: Vocal quality may also come and go depending on the use of the voice. During times of high use, the voice will worsen and tire. The child may have to strain to have any voice at all and at times may not be able to make appreciable sound. With rest, the voice usually returns, but may remain strained.
• Special challenges in the child-patient: Symptoms of reflux are very difficult to elicit in children. Children may not know what reflux is. They may experience reflux and not know that it is abnormal. Finally, reflux to the level of the larynx does not have to happen very frequently to cause significant problems in the larynx, according to adult research.

  Questions such as, "Do you ever feel like you throw up but it doesn't come all the way up and you swallow it?" or "Do you ever have wet smelly burps?" may help identify children who are refluxing.

The physical exam is often normal in children with voice disorders. It is not until the larynx is visualized that the abnormality is seen.

• If there are breathing problems associated with hoarseness, plain radiographs of the neck and the chest help physicians see the area just below the vocal folds, the subglottis, and the trachea.
• A direct examination of the voice box or larynx is necessary for diagnosis or treatment. The larynx can be seen with a flexible telescope through the nose or with a rigid telescope through the mouth. The structures of the larynx are seen and evaluated. Movement of the vocal folds, the vibration pattern of the vocal folds using stroboscopic lighting, and the anatomy of the surrounding structures are also evaluated. (For more information, see Laryngoscopy/Stroboscopy.)
• Direct laryngoscopy requires a general anesthetic to allow the larynx to be seen close up and palpated. After a safe general anesthetic is achieved, laryngoscopes can be passed through the mouth to expose the larynx directly. A magnified view of the structures of the larynx can be seen with telescopes and microscopes. Microlaryngeal instruments can be used to manipulate the fine structures of the larynx to determine the cause of the hoarseness. There may be a mild sore throat but generally there is no significant discomfort after this examination.
• Role of the speech language pathologist: The speech language pathologist is an integral part of the team that evaluates hoarseness in children. These clinicians subjectively assess the voice. They also have voice recording machines that can be used to help analyze the quality of the voice and document changes during treatment.

For children and adults, going to the doctor is often an anxiety-evoking experience. For children, most well-child checks include vaccinations. Mentioning a trip to the doctor is usually associated with the pain of a shot.

A trip to the otolaryngologist and speech language pathologist may also be frightening to the child. During the visit, the child and parent will be asked questions and then the child will be examined. The examination will include many familiar things like looking in the ears, nose, and throat and feeling the neck. Some radiographs (x-rays) may be taken and this will be just like getting a picture taken.

The otolaryngologist may also decide to look at the voice box or vocal folds. This can be done in a couple of different ways, and it really depends on the child which way will be best.

• One examination uses a camera attached to a shiny tube with a bright light. With the child's tongue sticking out, the physician inserts a tube inside the mouth and looks straight down at the vocal folds. It is then possible to videotape the vocal folds opening and closing during breathing and speaking.
• A light flashing at nearly the same frequency of the vocal folds is also used so the vibration of the vocal folds can be examined (stroboscopy). This technique allows the examination of the vibration function of the vocal folds, which is critical to voice production.
• The telescopes used in stroboscopy can be used in children who are older than five or six. Some patients cannot tolerate the camera in their mouth, because it causes them to gag. Panting can help, but occasionally it is impossible to complete the examination.

• In cases when the rigid telescope cannot be used inside the mouth to look at the larynx, a flexible telescope can be inserted through the nose to look at the voice box. This can be used in children under age 5 and anyone else who cannot tolerate examination through the mouth. Often a topical anesthetic and decongestant are sprayed in the nose. This makes the mucosa in the nose shrink to facilitate insertion of the telescope and also numbs the nose so that the procedure is less uncomfortable.
• The lighted flexible telescope is steered through the largest passages of the nose to the back of the throat where the voice box can be seen. Videotaping and stroboscopic evaluations are possible.
• The discomfort experienced during this procedure is due to the fact that something is deep inside the nose, while our reflex is to keep things out of the nose. Once the scope is in proper position, most children tolerate the procedure very well.
• A note on crying: Crying does not inhibit the otolaryngologist's and speech language pathologist's ability to complete the examination successfully. No one likes to make children cry, but it is important to have a good look at the vocal folds as well as their motion and vibratory characteristics. Sedation for this procedure is not possible as it would blunt the child's ability to follow directions and speak during specific parts of the examination.

Different children require different coaching from the parent prior to the visit. Some do best without any preparation. Others benefit from being told that they are going to the doctor to help them with their voice. The doctor may make a movie of their voice box with a camera.

Key Information

Evaluation of Voice Disorders Needs to Be Carefully Done

• A trained otolaryngologist should evaluate voice disorders in children (abnormal cry or hoarseness with or without noisy breathing). Evaluation in a Voice Center is ideal, especially in complex cases.
• Visualization of the voice box or larynx is critical to the diagnosis of voice disorders, and should be done with the right equipment.
• Nodules of the vocal fold will be the most common diagnosis for pediatric voice disorders, but the other rare causes of hoarseness must be ruled out by visualizing the vocal folds.

Red Flag

Especially in hard-to-manage children, voice disorder must not be diagnosed as a psychiatric or psychological problem unless voice specialists evaluate the voice box and voice function.