What Causes Hoarseness?

Patient Presentation
A 3-month-old male came to clinic because of rhinorrhea and a cough for 2 days. The cough was increasing in frequency and force but he had no respiratory distress, color changes or difficulty feeding.
He was afebrile. His sibling also had similar symptoms. His mother was very concerned because he sounded hoarse but his sibling did not. His cry also sounded hoarse to the mother.
The past medical history found him to be a former 33 week gestation premature twin infant, with an uncomplicated prenatal history, who had mild respiratory distress at birth that required nasal canula oxygen for several days but no intubation.
The family history was positive for heart disease and cancer.
The review of systems was negative.
The pertinent physical exam showed a not ill-appearing infant with heart rate = 140 beats/minute, respiratory rate = 34 breaths/minute, blood pressure = 74/58 mm Hg, and growth parameters in the 25-50% percentile. Pulse oximeter was 96% on room air. He had mild clear rhinorrhea. Lungs were clear but there were some transmitted upper airway sounds. No stridor was heard. His cry and cough did have a huskiness to them.
The diagnosis of an upper respiratory infection was made. The mother was counseled regarding symptomatic care and signs of respiratory distress to call about. She asked about the need for Synagis® for respiratory syncytial virus (RSV) prevention, but was told that he did not receive it before discharge because his gestation was too old to meet guidelines and that the season for this virus had passed.
She also asked if this could be subglottic stenosis. The physician responded that this was a potential possibility but was not as common as a cold.
She also told the mother that if this was subglottic stenosis that with the mild symptoms the infant was having, no evaluation or treatment would be undertaken at this time. The physician also discussed the natural history of subglottic stenosis and that most infants have improvement over time.

Discussion
Dysphonia is commonly described as the voice or cry being as hoarse, raspy, husky or even “having a frog in the throat.” The cause is a disturbance in the vocal fold vibration.
Timing of the onset of symptoms assists in the differential diagnosis with congenital and neurological conditions presenting at birth and anatomic, neurologic, neoplastic, inflammatory, infectious and iatrogenic causes presenting after birth.
History and physical examination help with the diagnosis but consultation with an otolaryngologist, speech and language pathologist, radiologist and other specialists may be necessary for evaluation and treatment.

Learning Point
The differential diagnosis of hoarseness or dysphonia includes:

  • Anatomy
    • Vocal cord/fold nodules – caused by overuse of voice, gets worse with more use of voice
    • Cysts – ex. mucous retention, epidermoid, saccular
    • Glottic web
  • Iatrogenic
    • Subglottic stenosis
    • Arytenoid subluxation
    • Vocal cord/fold paralysis – secondary to surgery
  • Infection – edema of the vocal cord/folds most often caused by viruses is the most common cause of hoarseness in children
    • Viral – ex. common cold, croup (parainfluenza virus) and RSV
    • Bacterial – ex. epiglottitis (Haemophilus influenza), Staphlococcus aureus
    • Fungus
    • Tuberculous
  • Inflammation
    • Gastroesophageal reflux
    • Connective tissue diseases – rare in children
  • Neophasia – rare
    • Benign – ex. squamous papilloma, adenoma, neurofibroma, hemangioma, etc.
    • Malignant – ex. squamous cell carcinoma, adenocarcinoma, fibrosarcoma, etc.
    • Recurrent respiratory papillomatosis – is viral in cause but acts neoplastic. Fine, warty-appearing papillomas grow at the squamociliary junction of the aerodigestive tract. Medical and surgical treatment is used to prevent overgrowth and airway compromise.
      However, recurrence is common.
  • Neurologic
    • Vocal cord/fold paralysis – due to an underlying neurologic condition, may be uni- or bi-lateral, the cry can be weakened or near normal and can be high-pitched.
  • Other
    • Drugs of abuse – cocaine
    • Hypothyroidism
    • Psychologic crisis
    • Trauma
    • Reinke’s edema – from smoking

Questions for Further Discussion
1. What are indications for referral to an otolaryngologist or speech and language pathologist?
2. What surgical procedures are available for recurrent respiratory papillomatosis?
3. What are risk factors for subglottic stenosis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Voice Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

McMurray JS. Medical and Surgical Treament of Pediatric Dysphonia. Otolaryngologic Clinics of North America. 2000;33:1111-1126.

Van der Goten A.
Evaluation of the Patient with Hoarseness.
Eur Radiol. 2004.;14(8):1406-15.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    September 24, 2007

  • What Are The Laws In My State for Teen Driving?

    Patient Presentation
    A 15-year-old male came to clinic for a sports physical. During the interview he said that he was really excited because he had just gotten his driving learner’s permit.
    His mother expressed ambivalence because she thought that he would be able to get his full license too soon, yet she was looking forward to having him help by driving his younger sister to various activities.
    The social history revealed a teenager who was an A-B student, active in music and art, and with a stable circle of friends that his parents liked.
    The pertinent physical exam showed a healthy teenager with growth parameters in the 50-90%. He had mild comedomal acne on his face.
    The diagnosis of healthy teenager was made. The physician discussed with the teenager and parent some of the risk factors for increased crashes and injuries such as teenage passengers in the car, nighttime driving, speeding, not using seat belts and having distractions in the car such as music, eating, or cellular telephone use.
    The family was well-aware of the state’s graduated driver licensing laws, but the physician also noted that the parents could decide on their own “family laws” which could be more restrictive. She also printed a sample teen driver contract for the family from the Academy of Pediatrics’ website for the family to consider when talking about the rights and responsibilities of driving.

    Discussion
    Motor vehicle accidents are the leading case of death for 16-20 years olds in the United States, resulting in ~5500 fatalities yearly. Teenage drivers are only 6% of drivers but account for 14% of the fatal crashes.
    The younger the driver, the higher the crash rates. Males have higher crash rates and fatalities than females.

    There are many reasons for these higher rates including:

    • Driving inexperience – driving is a complex activity that the teen has not yet learned
    • Increased risk taking – as a part of normal adoelscent behavior
    • Nighttime driving – it is more difficult to drive at night
    • Drug, alcohol and medication use – impairs judgement
    • Distractions – using a cellular telephone, eating, etc. Teenage passengers are especially a problematic distraction.
    • Unlicensed drivers
    • Safety belt use – teenagers use seatbelts less often than adults
    • Attention deficit hyperactivity disorder
    • Vehicles driven – teens tend to drive smaller, older model cars which tend to have less safety features, sporty vehicles may also encourage speeding

    Learning Point

    Graduated driver licensing (GDL) was first put into effect in Florida in 1996. In 2007, 44 states have some type of GDL law.
    GDL laws phase in on-road driving that allows inexperienced drivers to gain experience under lower risk situations and gradually introduces then to more complex situations as they gain experience.
    There are 3 general stages:

    • Learner’s licensing stage – where driving is permitted under direct supervision
    • Intermediate licensing stage – where driving is not directly supervised but allowed only in less risky situations (i.e. daytime driving or limited nighttime driving, no passengers or limited passengers)
    • Full licensing stage – when the driver has shown proficiency at the first two stages

    The GDL laws vary by state with substantial variations in the exact policies for the stages and the time period for each stage. A comprehensive listing of current state laws can be found in the “To Learn More” section below.

    Studies support the efficacy of GDL laws.
    One study showed GDL laws decreased injuries and fatalities for 16 year old drivers by 38-40%.

    According to the Insurance Institute for Highway Safety “In an optimal system, the minimum age for a learner’s permit is 16; the learner stage lasts at least 6 months, during which parents must certify at
    least 30-50 hours of supervised driving; and the intermediate stage lasts until at least age 18 and includes both a night driving restriction starting at
    9 or 10 p.m. and a strict teenage passenger restriction allowing no teenage passengers, or no more than one teenage passenger.”

    A sample teen driving contracts between parents and the teenage driver which outlines the privileges and responsibilities of driving are available in the “To Learn More” section below.

    Questions for Further Discussion
    1. What are the driving laws for teenagers who work in agriculture?
    2. What are the driving laws restrictions for people with different medical conditions such as seizures?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Motor Vehicle Safety.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Insurance Institute for Highway Safety and Traffic Injury Research Foundation. Graduated Licensing:
    A Blueprint for North America.
    Available from the Internet at http://www.iihs.org/laws/state_laws/pdf/blueprint.pdf (rev. August 2004, cited 7/19/2007).

    National Highway and Transportation Safety Administration. Graduated Driver Licensing.
    Available from the Internet at http://www.nhtsa.dot.gov/people/injury/NewDriver/GraduatedDriverLicense/index.htm (rev. September 2006, cited 7/19/2007).

    American Academy of Pediatrics Policy Statement. The Teen Driver. Pediatrics 2006:18;2570-2571. Available from the Internet at: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;118/6/2570.pdf (rev. December 2006, cited 7/19/2007).

    Barker SP, Chen L, Li G. Nationwide Review of Graduated Driver Licensing. AAA Foundation for Traffic Safety.
    Available from the Internet at http://www.aaafoundation.org/pdf/NationwideReviewOfGDLSummary.pdf (rev. February 2007, cited 7/19/2007).

    Insurance Institute for Highway Safety. U.S. Licensing Systems for Young Drivers.
    Available from the Internet at http://www.iihs.org/laws/state_laws/pdf/us_licensing_systems.pdf (rev. May 2007, cited 7/19/2007).

    Allstate Insurance Company. Parent-Teen Driving Contract. U.S. Licensing Systems for Young Drivers.
    Available from the Internet at http://www.allstateteendriver.com/files/parent-teen-contract.pdf (rev. 2007, cited 7/25/2007).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    September 10, 2007

  • What Should I Order for An Immune Workup?

    Patient Presentation
    A 3-year-old male came to the emergency department with sudden onset of a fever to 42° C and a rash that began about 1 hour previous.
    The mother said that he had been well but suddenly felt very warm and she noticed a red rash on the trunk that seemed to be spreading to the face and extremities. He also seemed to be breathing faster.
    The past medical history revealed that he had several ear infections and mother says he always seems to be coughing. His immunizations were current.
    The family history was negative.
    The review of systems was negative including upper respiratory tract symptoms, nausea, vomiting, diarrhea, dysuria, etc.
    The pertinent physical exam showed a male who appeared toxic, flushed in the face and was crying but who appeared oriented. He had a heart rate of 164, respiratory rate of 48, blood pressure of 56/34, and a weight of 13 kg (10% percentile). Pulse oximeter was 94%.
    Capillary refill was > 3 seconds. His skin had petechiae on the chest, abdomen, face, upper arms and legs and new lesions were appearing during evaluation, particularly in areas of trauma such as tourniquets and venipuncture sites.
    His heart had a II/VI murmur, consistent with a flow murmur at the lower left sternal border radiating upward. Lungs had clear breath sounds.
    Abdomen and genitourinary systems were negative.
    The patient’s clinical course of presumed sepsis was made and the patient was immediately treated with intravenous fluids, oxygen, dopamine and ceftriaxone.
    and the PICU was called.
    The stat laboratory evaluation showed an arterial blood gas of 7.32/90/32/-15. The hemoglobin was 11.3 mg/dl, platelets were 118 x 1000/mm2, and white blood cells of 12.5 x 1000/mm2 with 40% polymorphonuclear cells and 0% bands.
    Blood cultures, urine cultures and a chest radiograph were ordered.
    The patient was transferred to the PICU and continued to deteriorate into a coma with hypotension, respiratory distress, spreading purpuric rash and disseminated intravascular coagulopathy. He required intubation and epinephrine and norepinephrine drips.
    Cefotaxime and gentamicin were given. The chest radiograph showed clear lung fields but dextrocardia noted. The peripheral blood smear showed Howell-Jolly bodies.
    Five hours later despite maximal blood pressure and ventilator management, the patient coded and resuscitation was unsuccessful.
    The family refused an autopsy. Twelve hours after admission to the emergency room, the blood culture grew a Streptococcus species that was later confirmed as Streptococcus pneumoniae.
    The diagnosis of sepsis secondary to Streptococcus pneumoniae was made. The possible diagnoses of situs inversus viscerum with functional asplenia, or possibly a complement deficiency and asplenia were considered as possible primary causes of the sepsis.

    Discussion
    Children with immunodeficiencies can present in many ways including failure to thrive, weight loss, poor weight gain, diarrhea, cough, recurrent infections, unusual infection organisms, or unusual infection organ locations, and as in this case, sudden onset of an overwhelming infection.
    There is no absolute indicator as to when a child should be evaluated for a potential immune problem but the following can be considered:

    • Systemic bacterial infections, 2 or more, e.g. sepsis, meningitis, deep abscess
    • Bacterial infections, 3 or more, e.g. draining otitis media
    • Upper respiratory infections, > 6-8 in one year
    • Recurrent infection of same organism, e.g. meningococcemia
    • Need for surgical treatment, e.g. drainage of abscess, lobectomy for chronic pneumonia
    • Failure to thrive, weight loss or growth retardation
    • Unusual infections, i.e. Pseudomonas carinii in a presumably normal child

    A through history of all infections and family history of infection or death is important.
    Physical examination should look at growth parameters, clues of allergies (eczema, allergic shiners, wheezing), lymph nodes including tonsillar tissue (absence may indicate B-cell dysfunction), cardiac murmurs (i.e. DiGeorge syndrome) and ataxia (i.e. ataxia-telangiectasia)

    Learning Point
    Specific testing for immune disorders depends on the constellation of findings especially in the history which is then influenced by the physical examination.
    Testing usually includes general screening tests as well as more specific tests for various components of the immune system. Some testing is not easily available and may be expensive. Patient evaluation and interpretation of the testing may necessitate consultation with an immunologist or hematologist/oncologist who is familiar with and treats such patients.
    Immunological testing may include (common screening tests are *) :

    • B-Cells
      • *Immunoglobulin levels (i.e. IgM, IgA, IgG)
      • *Antibody titres to vaccines previously given or isohemagglutinins
      • B-cell phenotyping by flow cytometry
    • T-Cells
      • Delayed hypersensitivity skin testing by intradermal injection of common antigens (i.e. candida)
      • T-cell phenotyping by flow cytometry
      • T-cell proliferation testing to mitogens
    • Complement
      • *CH50 (total hemolytic complement)
      • Assays of individual components of the classic and alternative pathways, C3, C4
    • Phagocytic disorders
      • Neutrophil phenotyping by flow cytometry
      • Respiratory burst activity
    • General tests
      • Complete blood count with differential and platelets, *absolute lymphocyte count, *absolute neutrophil count
      • Peripheral blood smear for Howell-Jolly bodies, *neutrophil morphology
      • *HIV
      • Sweat test
      • Allergen skin testing
      • Erythrocyte sedimentation rate

    Questions for Further Discussion
    1. List some primary B-cell immunodeficiency disorders.
    2. List some combined immunodeficiency disorders.
    3. What does a Howell-Jolly body look like?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Sepsis and Immune System Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:791-793.

    Fleisher TA. Back to basics: primary immune deficiencies: windows into the immune system.
    Pediatr Rev. 2006 Oct;27(10):363-72.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient managemnt plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    September 4, 2007