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Our goal is to provide your child and family comprehensive care of the larynx and voice. We want to address your child’s needs both now and as he grows into adulthood.
The larynx is a complex and fascinating structure that has the important responsibilities of helping you breathe, swallow and speak. We believe that all of these facets must be taken into consideration when making the proper management plans for your child.
Not all children with hoarseness suffer from chronic laryngitis or vocal fold nodules. Although vocal fold nodules are the most common cause of long-standing hoarseness in children, this is not always the case. Other, more worrisome, lesions are possible. It is important, therefore, that all children with hoarseness that does not go away after a few weeks are properly evaluated.
Vocal fold nodules
Vocal fold nodules are similar to calluses on the vocal folds. Nodules most commonly result from phonotrauma, or the way the vocal folds strike together when a child speaks. The nodules are benign but can cause persistent hoarseness or even pain when speaking. Treatment often includes voice therapy.
Vocal fold cysts or polyps
Vocal fold cysts or polyps are lesions on the voice folds that can prevent the vocal folds from closing and vibrating. Lesions can be filled with fluid, mucus, or blood. Patients usually present with persistent hoarseness or pitch changes. Treatment is often surgical excision to obtain a definitive diagnosis and prevent permanent hoarseness.
Vocal hemorrhage, or bleeding into the vocal folds can present with sudden hoarseness or loss of voice. The hemorrhage is often, but not necessarily, related to an episode of strenuous voice use or coughing. Early diagnosis is important to prevent permanent scarring or changes to the vocal folds. Some patients may need surgery to prevent recurrent hemorrhages.
A granuloma is an area of swollen or inflamed tissue that can occur anywhere in the body. In the voice box, granulomas are most commonly found near the joints of the vocal folds. Granulomas may form following vocal trauma or local injury (such as having a breathing tube placed with any surgery). Granulomas may cause voice changes and even breathing difficulties if large enough. Treatment needs to be tailored to the individual and may include medications, voice rest, and/or surgery.
Papillomas are wart-like lesions that can be found anywhere in the airway tract. The lesions are caused by the human papilloma virus (HPV). In children, presenting symptoms may be voice changes or breathing difficulties. If left untreated, papillomas may grow large enough or spread and make it hard for a child to breathe. There is also a small chance that untreated papillomas could become cancerous. Correct diagnosis and surgical treatment is important. Goals with surgery include removing as much papilloma as possible while safely preserving normal voice box structures. It is not uncommon for papilomas to recur even with treatment.
Vocal fold scarring
Vocal fold scarring can occur after trauma to the vocal folds. This is also called sulcus vocalis. The scarring prevents the vocal folds from vibrating properly and can result in a hoarse or raspy sounding voice.
Glottic (vocal fold) and subglottic webs
Children can have webs, or tissue bridges, at the front of or just below the vocal folds. Some children are born with the webs; others form the webs after trauma or surgery. The vocal fold webs may be small and not cause any problems. Larger webs can make it difficult for a child to breathe and have a normal voice.
Vocal fold paralysis or immobility
Vocal fold immobility is when one or both of the vocal folds do not move as expected. It may be related to a nerve injury, joint or muscle problem. The affected vocal fold may have weak movement or no movement at all. This condition may occur following a viral infection, surgery, intubation for surgery, or tumors or malformations in the skull base, neck or chest. Symptoms can range from mild vocal fatigue to choking/coughing while drinking liquids to breathing difficulties. Treatment depends on the cause of the immobility as well as any resulting symptoms. Options for treatment may include voice therapy, office based treatments in select patients or surgery in the operating room.
Vocal fold inflammation due to gastroesophageal reflux or laryngopharyneal reflux (LPR)
Small amounts of acid from the stomach may reflux to the back of the throat and irritate the voice box. This irritation may cause hoarseness, chronic coughing, frequent throat clearing, or a ball sensation in the back of the throat. Often times, inflammation of the voice box can be seen after examination. Treatment may include dietary or lifestyle modifications to limit reflux or anti-reflux medications.
Vocal fold dysfunction or paradoxical vocal fold movement
Vocal fold dysfunction is when the vocal folds move inward instead of opening up when you breathe. Symptoms of shortness of breathe and difficulty-getting air in can occur suddenly and be very frightening. Proper diagnosis includes a full ear, nose, and throat examination and airway evaluation. Treatment may include avoidance of triggers, medical treatments, and voice therapy.
Muscle tension dysphonia
Muscle tension dysphonia can occur when the muscles of the larynx squeeze harder that they should in order to produce a voice. This can occur in isolation or as a response to another voice box problem. When severe, muscle tension dysphonia can make it difficult or even painful to speak. The voice often sounds strained and rough sounding. Treatment for muscle tension dysphonia is non-surgical and typically involves voice therapy.
Laryngeal and subglottic stenosis
Laryngeal stenosis is narrowing of the airway just above, at, or just below the vocal folds. When just below the vocal folds, this is known as subglottic stenosis. The narrowing is most commonly related to trauma from prolonged intubation. It may be worsened by reflux, caustic ingestions, respiratory infections, surgery, or external injuries to the neck and voice box. Narrowing of the airway in this area can cause noisy breathing or stridor (a high pitched whistling noise when breathing). The narrowing can be significant enough that a child has difficulties breathing. Treatment of the stenosis is dependent on the severity of narrowing and overall health of the patient. Endoscopic surgeries or open neck surgery may be needed.
Many of the other laryngeal diagnoses can occur following laryngeal trauma. Proper management requires complete evaluation and consideration of breathing, swallowing, and voice in the context of the individual patient.
Professional voice users have specialized needs. We consider their larynx to be their instrument and like any instrument, require long-term care. Whether aspirations include professional singing, teaching, or acting, we understand that the needs of these children may differ from other kids. It is often important to have a baseline examination of the larynx so that any future problems are more easily recognized and treated.
We are grateful to have been ranked #1 on U.S. News & World Report's list of the best children's hospitals in the nation for the third year in a row, an honor we could not have achieved without the patients and families who inspire us to do our very best for them. Thanks to you, Boston Children's is a place where we can write the greatest children's stories ever told.”