Understanding 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

This section contains information on the following:

• Voice disorders in newborns
• Voice disorders in children

Voice Disorders in Newborns

In a newborn, an abnormal cry and/or noisy breathing (stridor) indicate problems in the voice box (larynx). Stridor may accompany potentially life-threatening conditions.

Red Flag

• Noisy breathing (stridor) is a sign of obstruction or narrowing of the laryngeal or tracheal parts of the airway.
• Stridor is a sign of difficulty passing air.
• Any breathing difficulty needs immediate medical attention.

• Anything that creates a blockage in the breathing passages causes turbulence in the passage of air, which then makes breathing noisy (stridor).
• Stridor can occur while breathing in, while breathing out, or during both phases of the breathing cycle.

• Stridor is most often seen when infants are awake and active or feeding.
• When the child is awake and active, increased rates of breathing often exacerbate the turbulent airflow and noisiness.

• Occasionally, children are noisy breathers when sleeping.
• This is a sign of a partial airway obstruction that worsens when the hypopharynx and larynx relax.
• Any obstruction(s) in the upper part of the airway should be investigated.

• Noisy breathing that only occurs during feeding or sleep and that resolves during crying is a sign of blockage in the nasal cavity.
• This is called paradoxical stridor because the infant breathes better when active or agitated rather than when quiet.

Key Information

Obligate Nose-Breathers

• Infants are obligate nasal breathers (breathe through the nose only; do not know how to breathe through the mouth) until about the age of three to four months.
• Any blockage in the nose and nose cavity can cause significant noisiness – even gasping – in a newborn.

Effects on Feeding

• Any child with persistent progressive noisy breathing should be evaluated by a practitioner familiar with breathing disorders in children. Often, no therapy is required. However, the child should be followed closely to be certain that he or she grows and gains weight properly.
• The very young must learn quickly to coordinate the suck-swallow-breathe cycle. Minor changes in this cycle due to airway obstruction may interrupt their ability to feed. Failure to thrive or grow is an important indicator of the severity of their breathing disorder.

• Laryngomalacia, or "floppy larynx," is a very common cause of noisy breathing in children.
• Typically, these children develop noisy breathing during inhalation within weeks of birth. The noise they make is a high-pitched squeak on inhalation that worsens with activity such as crying or feeding.
• Floppy larynx is caused by collapse of the epiglottis and other structures above the vocal folds during inspiration. The exact cause of the collapse is unknown. (For more information, see Anatomy & Physiology of Voice Production.)

The diagnosis of laryngomalacia is made by history and physical examination. The physical examination includes visualization of the upper airway during breathing to confirm the diagnosis.

In some cases further examinations, such as x-rays of the neck and chest, may be required. A more detailed viewing of the throat and voice box area (laryngoscopy), esophagus (esophagoscopy), and trachea and bronchi (bronchoscopy) might also be required.

The floppiness of the larynx is transient and typically resolves during the first year of life. If the child is able to gain weight and grow at expected rates, no treatment is required. Frequent assessment of weight gain should be taken for this purpose.

Although rare, severe cases of laryngomalacia may need surgical correction of the floppy parts of the larynx to provide an adequate airway.

• Microlaryngeal Surgery: Specialized surgery, performed with microsurgical tools and through a surgical microscope (microlaryngeal surgery), may be required in severe cases to relieve the obstruction and allow the infant to coordinate the breathing and swallowing cycles. The surgery aims to carefully remove the floppy parts of the larynx that collapse into the voice box inlet (laryngeal inlet) while making sure that voice function remains intact.

Often, treatment for laryngopharyngeal reflux is instituted in children with laryngomalacia. (For more information, see adult Reflux Laryngitis.) Laryngopharyngeal reflux is often seen in infants with laryngomalacia for several reasons.

• With the increase in the "work" of breathing, air is often swallowed during feeding, causing distention of the stomach. This then makes it easier for stomach fluids to backflow toward the food pipe (esophagus), eventually reaching the lower throat (hypopharynx) and voice box (larynx).
• With the floppy larynx collapsing during inhalation, efforts to breathe can result in a lower pressure in the chest. This makes it easier for stomach fluids to backflow toward the food pipe, lower throat, and voice box.
• Edema (swelling) from reflux creates a narrower breathing passage, which exacerbates the laryngomalacia.

An abnormal cry in newborns has many possible causes. They can be broadly grouped into congenital or neurologic causes.

• Description: The vocal folds are supposed to separate during development. Rarely, this separation does not occur and a web of tissue is left across the laryngeal inlet. This is called a laryngeal web or glottic web.
• Effects on breathing: Breathing is possible because the back portion of the larynx, where the arytenoids cartilage attaches to the vibrating part of the vocal fold, is usually not associated with the web. The child's cry may be characterized as weak. Occasionally, stridor also results from the mild narrowing of the glottic inlet.
• Diagnosis: Generally, children with laryngeal webs are not diagnosed until after the first or second year of life. The diagnosis is made by diagnostic endoscopy. Radiograms may also be helpful to determine the length of the web. A lateral neck radiograph may show the classic "sail" sign.
• Treatment: Surgical correction usually entails expansion of the subglottic cartilage as well as lysis of the web across the membranous vocal fold.

• Description: Congenital cysts are mucus-filled sacs that develop on the vocal folds. Cysts usually result in abnormal cry.
• Effects on breathing: Children with congenital cysts may also develop some problems with breathing.
• Diagnosis: Diagnosis is usually possible with diagnostic endoscopy.
• Treatment: Surgical excision of the cysts is necessary, as they will generally enlarge as the sacs fill with mucus. Endoscopic approaches through the mouth as well as external approaches through the neck are possible. The recommended technique depends on the situation of the individual child.

• Description: Hemangiomas are benign tumors made up of blood vessels (capillaries) that uncontrollably increase in number. When hemangiomas occur on the vocal folds or in the area underneath the voice box, hoarse cry and/or noisy breathing usually result.
• Typical Behavior of Hemangiomas:
  • Begins to grow in the first months of life: Generally, the tumor begins to grow within the first weeks to months of life and may be associated with other vascular birthmarks.
  • Enlarges, then shrinks: The tumor usually will begin to shrink or regress after the first year of life. The timetable for shrinking/regression is not predictable, however.
  • Even if it becomes large, it is not cancerous: Although they increase in size and can become large, hemangiomas are not cancerous (malignant).
• Treatment: Treatment varies depending on the size, location, and progression of the hemangioma. Physicians and patients must balance the need to intervene with waiting, since hemangiomas eventually shrink. In particular, treatment plans must be made cautiously to prevent any damage to structures in the voice box (larynx) or the area underneath the voice box (subglottis).

Red Flag

Very Large Hemangiomas Can Cause Problems Related to Breathing, Heart Function, and Bleeding Control

• Breathing difficulties: The size of the hemangioma can block the airway passage, making it difficult to breathe.
• Heart workload increased: The heart has to work harder in order to circulate the blood in the hemangioma and throughout the body.
• Imbalances in the control of bleeding: The hemangioma can cause an imbalance in the different cells and substances involved in the control of bleeding, to the point that a bleeding disorder can result.

Key Information

Airway problems can occur. When airway problems do occur, there are some surgical techniques that can be used to try to avoid a tracheostomy when airway obstruction and breathing problems become evident.

Neurological causes of hoarseness in newborns are generally related to paralysis of one or both of the vocal folds.

• Description: Bilateral vocal fold paralysis causes more breathing problems than voice problems. Although the cry may be a little weak and breathy, noisy breathing is more evident.
• Reason for the breathing problems: Normal laryngeal nerves and muscles move the vocal folds to the closed position during crying, sound production (newborn), or speech/singing (older children and adults), and move the vocal folds apart during breathing. Two-sided vocal fold paralysis makes this impossible. The vocal folds stay close together during inhalation, causing a high-pitched, squeaky noise.
• Diagnosis:
  • Two-sided paralysis may look similar to laryngomalacia. Since the vocal folds are paralyzed in approximation, the voice may sound relatively normal and can fool even the experienced practitioner. Diagnosis relies on diagnostic endoscopy.
  • The vocal folds may have the appearance of motion but it will be paradoxical, moving in during inhalation (instead of opening) and out during exhalatio