Diagnosing Hoarseness in Children

Many children’s voices sound hoarse, rough, scratchy, tight, or weak when they’ve had congestion from a cold or a seasonal allergy. This can also occur after children have overused their voices, such as when yelling at a sporting event.

Congestion and overusing the voice can cause temporary inflammation in the vocal cords, or folds. These V-shaped, multilayered bands of muscle and mucous membrane vibrate together to produce sound in the larynx, also known as the voice box. Inflammation can interfere with the vocal cords’ ability to vibrate normally, causing hoarseness.

When hoarseness, vocal weakness, or another vocal problem continues for a few weeks or longer, it may be a chronic condition. Our voice specialists are experienced in evaluating children with chronic hoarseness or other unusual vocal qualities, such as cracking or weakness, to determine the cause of the condition.

Causes of Childhood Hoarseness

Frequently, children with chronic hoarseness have a benign—or noncancerous—lesion on one or both vocal cords. These lesions—bumps or lumps that arise underneath or on the surface of vocal cords—can prevent the vocal cords from opening and closing properly and from vibrating normally, which can change the way that air moves through them to make a sound.

There are several types of benign vocal cord lesions. Vocal cord cysts, for instance, are fluid-filled growths that usually form beneath the vocal cords before a child is born. Nodules and polyps, much like calluses and blisters, arise on the surface of the vocal cord as a result of overusing the voice.

Repeated injury to the vocal cords from shouting or talking too much causes inflammation. Inflamed tissues may stiffen and form growths.

Some children develop hoarseness after being treated with a breathing tube during surgery, which can cause scarring of the vocal cords. Surgery in the neck or chest can also damage nerves in the larynx, partially or completely preventing the vocal cords from moving normally and affecting a child’s ability to speak. This condition is known as vocal cord paresis, or paralysis.

Children who have neuromuscular conditions, such as muscular dystrophy or cerebral palsy, may experience vocal cord spasms that can make the voice sound weak.

Gastroesophageal reflux disease, or GERD, in which digestive acids in the stomach flow back up into the esophagus—the tube that connects the mouth to the stomach—can also irritate the larynx, causing hoarseness. However, GERD tends to cause hoarseness more often in adults than in children.

Children who have sleep apnea, which causes snoring and gasping for breath during the night, may also develop a hoarse voice as a result of mouth breathing, which can dry out the vocal cords and cause inflammation.

Most childhood vocal cord lesions or other causes of hoarseness are not serious concerns, but they do require a thorough evaluation. Our voice specialists use the following tools to evaluate your child’s vocal cords and determine the underlying cause of hoarseness or other vocal problems.

Vocal Evaluation

At Hassenfeld Children’s Hospital at NYU Langone, laryngologists, who diagnose and treat conditions that affect the larynx, perform a vocal evaluation to identify problems your child may have in producing sound. During the evaluation, a speech pathologist—a specialist who diagnoses and treats vocal conditions—asks your child to say a few words or sentences and to make different sounds.

The doctor listens to how your child’s voice sounds at different pitches. Pitch refers to the speed of the vocal cords’ vibrations: a low-pitch voice vibrates more slowly and sounds deeper than a high-pitch voice. Your doctor may ask your child to speak in both a high-pitch and a low-pitch voice to assess the condition of the vocal cords.

This evaluation may be recorded so that our laryngologists and speech pathologists can listen to your child’s voice in greater detail after the exam, which can help to identify specific problems. The recording may also be used as a baseline to monitor the progress of treatment.

A computer analysis of the recording can be used to obtain more detail about your child’s hoarseness.

Flexible or Rigid Transoral Laryngoscopy

Your doctor may perform flexible laryngoscopy at the same time as a vocal exam. This test allows the doctor to look at your child’s vocal cords to identify cysts or nodules.

Immediately before the test, the doctor sprays a topical anesthetic in your child’s nose to numb the nasal passages and throat. After the area is numb, the doctor inserts a thin, supple tube called a flexible laryngoscope through one of the nostrils and into the larynx. The laryngoscope is attached to a tiny high-definition camera, which enables the doctor to see the vocal cords clearly on a monitor.

During flexible laryngoscopy, the doctor may ask your child to repeat certain sounds and words to see how the vocal cords are working and the precise location of the problem. This test is performed in the doctor’s office and takes about two minutes.

A rigid transoral laryngoscope, also performed in the doctor’s office, may be used if your child has a deviated septum or a blockage in the nasal passages. These conditions make it difficult to insert a flexible laryngoscope through a nostril.

After spraying a topical anesthetic into your child’s throat, the doctor inserts a thin, metal laryngoscope through the mouth and into the larynx. The high-definition camera attached to the tip of the laryngoscope shows the vocal cords on a monitor. Rigid transoral laryngoscopy typically takes two minutes to perform.

During flexible or rigid transoral laryngoscopy, the doctor may use a technique called laryngeal video stroboscopy to look for scarring and structural problems in the vocal cords. In most people, the vocal cords vibrate between 120 and 240 times per second during a conversation—much faster than the human eye can see.

Stroboscopy uses rapid flashes of light from a strobe light attached to the laryngoscope. This allows the doctor to observe vocal cord vibrations in slow motion, revealing subtle changes in the structure of the vocal cords, such as scarring or other problems. It does not add extra time to the exam.

Microlaryngoscopy and Biopsy

If doctors need a closer look at the larynx to evaluate scarring that’s possibly hidden by a vocal cord lesion, they may recommend microlaryngoscopy. Doctors perform this surgical procedure, which takes about an hour and requires general anesthesia, in the hospital.

The surgeon uses a laryngoscope to insert a tiny microscope into your child’s larynx and carefully lifts the vocal cord to obtain a highly magnified view of the area. The doctor may also perform a biopsy if necessary, removing a tiny area from the vocal cords, so it can be examined under a microscope to rule out cancer.

MRI Scans

The doctor may recommend an MRI scan to determine if your child’s hoarseness is caused by a growth on or near one of the nerves connecting to the muscles of the larynx, which can lead to partial or complete vocal cord paralysis.

During MRI scans, a large magnet and radio waves are used to make detailed, cross-sectional images of the larynx. An anesthesiologist may give your child a short-acting sedative, given through an injection into a vein, just before this procedure begins, to ensure that he or she stays still during the test.

The doctor uses the results of these tests to create a treatment plan that addresses the underlying cause of your child’s hoarseness.