Hoarseness in Children Is Often Misdiagnosed, Leading to Ineffective Treatment

Release: Immediate Contact: Kenneth Satterfield561-447-5521 (May 9-14, 2002)703-519-1563[email protected]

HOARSENESS IN CHILDREN IS OFTEN MISDIAGNOSED, LEADING TO INEFFECTIVE TREATMENT

A new study finds that a laryngeal examination will determine the true cause for pediatric voice problems; reflux laryngitis, not nodules, is often the culprit.

Boca Raton, FL -- Chronic hoarseness appears to be an increasingly common problem in children. The conventional wisdom in the medical community is that benign vocal fold nodules are the most common cause of this problem. This assumption often lulls the clinician into failing to provide an accurate diagnose. Consequently, ineffective vocal therapy is too often begun without visualization of the larynx.

The importance for children to develop their communicative skills without discomfort and undue effort and the need to explore alternative diagnoses for chronic hoarseness warrant another look at the cause for this pediatric disorder. Researchers in Buffalo, New York, set out to assess the perception of the presence of hoarseness in a group of children held by parents and ear, nose, and throat specialists and to identify other causes of voice problems found by laryngeal examination.

The authors of the study, "Perceptions and Etiologies of Chronic Hoarseness in Children," are Vito Brunetti, Vincent Callanan, MD, and Linda Brodsky MD, all from the State University of New York at Buffalo, School of Medicine and Biomedical Sciences; the Children's Hospital of Buffalo, Buffalo, NY; and Steve Shaha, PhD, Institute for Integrated Outcomes, Amherst, NY. Their findings will be presented May 12, 2002, at the Annual Meeting of the American Broncho-Esophagalogical Association, at the Boca Raton Resort & Club, Boca Raton, FL.

Methodology: The two primary components consisted of:

Parent Questionnaire. 166 parents and five attending pediatric otolaryngologists completed a questionnaire from August 15, 2001 through September 15, 2001. The questions asked of each were: "Is your (the) child hoarse, or have an abnormal voice quality?" Parental and physician impressions were then compared.

Laryngeal Diagnosis. From January 1, 1999 to December 31, 2000, 877 consecutive patients required laryngoscopy for evaluation at a children's hospital. Their results were evaluated to determine the efficacy of using a rigid and flexible laryngoscopy in evaluating pediatric otolaryngologic disorders of the upper aerodigestive tract. All children who had hoarseness either as a chief complaint or as an associated symptom identified during the history of present illness or on the review of systems were included in this study.

Reflux laryngitis was considered present if there was lingual tonsillar hyperplasia, posterior glottic swelling, and loss of arytenoids architecture. The presence of severe hypopharyngeal cobble-stoning, vocal fold edema and loss of ventricular architecture were also considered; however, conjecture alone would not suffice to make the diagnosis.

Results: Key findings included:

* Forty of 166 (24 percent) of children were perceived as being hoarse. Parents recognized 33 of 166 (19.8 percent); and the otolaryngologist identified another seven of 166 (4.2 percent) as having abnormal vocal quality. Eighteen of 166 (10.8 percent) presented with hoarseness as a chief complaint; 22 of the remaining 148 (14.8 percent) presented with other problems and were found to be hoarse on review of symptoms and/or physical examination.

* Some 227 of 877 (26 percent) of all laryngoscopies were performed in children with hoarseness: 122 (54 percent) presented with a chief complaint of hoarseness, while 105 (46 percent) had hoarseness identified on review of systems or physical examination. Younger children were more likely to present with hoarseness as part of a symptom complex rather than a chief complaint.

* The laryngeal diagnoses were: 165 of 227 (73 percent) had abnormalities consistent with reflux laryngitis; 68 of 122 (56 percent) of those presenting with a chief complaint of chronic hoarseness, and 97 of 105 (92 percent) of those who had hoarseness as an associated symptom. Almost all of these 97 patients had an airway symptom as their chief complaint, most often stridor/stertor, recurrent croup, or sleep disorder. A previous history of reflux was found in a total of 68 percent of children with hoarseness.

* The researchers found 127 of 227 (55.9 percent) had other or additional diagnoses including: true vocal fold nodules (n=70, 30.8 percent); laryngomalacia (n=33, 14.5 percent); recurrent respiratory papillomatosis (n=four, two percent); vocal fold paralysis n=10, 4.4 percent); and subglottic lesions (n=10,4.4 percent).

* Of the 93 percent completing therapy, 88.8 percent of these with reflux usually combined medical , dietary, and lifestyle change recommendations, improved ; 22.3 percent with vocal nodules underwent speech therapy for vocal nodules alone that remained after reflux was controlled -- but the voice continued to be hoarse. Surgery on the larynx (for voice, i.e. excluding laryngeal papillomata) was performed in 2.3 percent; fundoplication for reflux was performed in 3.3 percent.

Conclusions: Most causes of dysphonia (hoarseness) in children are associated with diseases that have a high potential for inflammatory reactions originating from a variety of mechanisms. Direct irritative effects are attributed to extra-esophageal reflux laryngitis. Chronic trauma from vocal abuse or from constant throat clearing (from reflux, sinusitis or allergy) appears to account for nodule formation. The researchers believe that vocal fold nodules no longer account for most cases of hoarseness in children. They contend that reflux laryngitis, often caused by diet and changes in lifestyle, is a common problem that requires a different therapeutic approach. Accurate diagnosis by a laryngeal examination, is most likely to facilitate appropriate and effective treatment.

- end -