Chronic Hoarseness

How Vocal Cords Work

When we inhale, oxygen travels through the nose or mouth and down the throat (pharynx), passing through the voice box and windpipe (trachea), to get to the airway passages in the lungs. This route is reversed when exhaling carbon dioxide from the lungs, or talking.

To speak, air is pushed out of the lungs. In the larynx, the vocal cords — a "V"-shaped band of muscle — prepare for making sound by tightening up and moving closer together. As air passes through the vocal cords, they vibrate. This vibration, combined with the movement of the tongue, lips, and teeth, is what makes the sound of the voice.

Chronic misuse of the voice can cause excess wear and tear on the vocal cords. They may stretch too far or rub together, causing small irritations that, if not allowed to heal, turn into small calluses, or vocal cord nodules.

Causes of Chronic Hoarseness

Vocal cord nodules are the primary cause of chronic hoarseness in children. They happen when kids do any of the following for a prolonged period of time:

• yelling, screaming, cheering, or crying
• raising or lowering the pitch of the voice
• speaking in a strained voice, like imitating animals or cartoon characters
• repetitive coughing or throat clearing
• singing or talking without adequate breath (diaphragm support)
• talking extremely loud or fast
• starting words forcefully

Nodules, or growths, on the vocal cords can also be caused by vocal cord paralysis (when vocal cord nerves lose their function), smoke inhalation, chronic sinusitis or allergies, hypothyroidism, gastroesophageal reflux disease (GERD), and radiation therapy (for those undergoing treatment for throat cancer).

Detecting Vocal Cord Nodules

A child with chronic hoarseness will be referred to an otolaryngologist (also called an "ears, nose, and throat" specialist, or ENT) for evaluation. The doctor will ask for a medical history, listen for strain or breathiness in the voice, and perform a diagnostic test that provides an internal view of the voice box and vocal cord function.

Tests include:

• Flexible laryngoscopy. During this exam, a tiny, pliable, fiber-optic tube with a camera attached to the end (called a scope) is passed through a nostril and into the throat to allow doctors to get a magnified view of the larynx. Kids are asked to speak, sing, sniff, cough, and make other sounds that cause the vocal cords to vibrate. Movements are recorded on a computer monitor so that specialists can analyze them later.
• Rigid laryngoscopy. This can be performed in the office for older kids, but very young children and others who cannot tolerate a flexible laryngoscopy will undergo this test in an operating room under general anesthesia. The rigid scope is passed through the mouth to provide the best view of the vocal cords. Images of the vocal cords (at rest) are recorded.
• Laryngeal stroboscopy. To get a more accurate view of the vocal cords in action, doctors pass either a rigid or flexible scope attached to a strobe light into the throat. The strobe light flickers in sync with the vibration of the vocal cords as a person speaks, making it easier for doctors to determine the frequency of movement. Because individual vibrations are too fast for the naked eye to distinguish, the strobe technology projects the vibrations in slow motion.

Practicing Vocal Hygiene

Treatment for hoarseness caused by vocal cord nodules involves making behavioral changes so that the vocal cords can heal. Speech therapists work one-on-one with kids and their families to promote good vocal habits, or what's called "vocal hygiene."

A typical vocal hygiene program will consist of:

• isolating medical conditions (like GERD) that aggravate vocal problems, then undergoing treatment
• modifying behaviors that cause distress to the vocal cords, like yelling
• learning how to take deep breaths and relax the muscles in the throat
• taking time to speak slowly and clearly
• staying properly hydrated throughout the day
• avoiding caffeinated beverages, like soda, which dry out the vocal cords

For kids with established bad habits — like talking loudly when they're excited or clearing their throats when they're nervous — it might be difficult to implement changes in the beginning. The first step is to make kids aware of the behavior and observe how often they do it.

Older kids may be able to consciously note (perhaps in a diary) how often they engage in the behavior, which is usually done unconsciously. Then they can practice the skills they've learned in therapy when at home, at school, and spending time with friends.

It's up to parents and other family members to encourage good vocal habits by setting a good example themselves. For example, rather than calling to kids from another room, walk into the other room to address them. Promote quiet times (perhaps for a half-hour each day) and using an "inside voice" when indoors.

Reward systems that encourage these new behaviors usually are successful in elementary schoolers. Parents can offer stickers, tokens, extra TV time, a later bedtime, or similar incentives to get kids on board with the new, healthier habits.

Reviewed by: Patrick Barth, MD Date reviewed: June 2011