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.

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.

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

    September 24, 2007