Chronic Hoarseness

What Does Being Hoarse Mean?

A hoarse voice is when someone sounds rough, raspy, or breathy when speaking. Hoarseness happens because the vocal cords are strained. In kids, this can happen from everyday things like cheering loudly at a ballgame, belting out a favorite song in the shower, or calling out to friends on the playground.

Sounding hoarse for a few hours or the day after a big game is nothing to worry about. Usually, the voice returns to normal on its own. 

But chronic hoarseness can lasts for days, weeks, or even months. If this happens, a child needs to be checked out by a doctor. Speech therapy may be needed to get the vocal cords back into perfect pitch.

What Are the Vocal Cords?

The vocal cords are delicate bands of tissue in the larynx (LAIR-inks), or voice box. When we speak, air pushes out of the lungs. In the larynx, the vocal cords — a "V"-shaped band of muscle — prepare to make sound by tightening up and moving closer together. As air passes through them, they vibrate. This vibration, combined with the movement of the tongue, lips, and teeth, is what makes the sound of the voice.

What Causes Chronic Hoarseness?

Chronic (long-lasting or ongoing) misuse of the vocal cords — from things like a lot of yelling or using the voice in an unnatural way — puts excess wear and tear on the vocal cords. They may stretch too far or rub together, causing small irritations. If these aren't allowed to heal, they turn into small calluses, or vocal cord nodules. Vocal cord nodules are the top cause of chronic hoarseness in children. 

Nodules can happen when kids do things like these for long periods:

• 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 taking a good breath
• talking extremely loud or fast
• starting words forcefully

Other causes of hoarseness include:

• growths on or near the vocal cords
• vocal cord paralysis (when vocal cord nerves lose their function)
• smoking, secondhand smoke, vaping
• chronic sinusitis or allergies
• hypothyroidism
• gastroesophageal reflux (GER)
• radiation therapy in those being treated for throat cancer

How Are Vocal Cord Nodules Diagnosed?

Doctors will want kids with chronic hoarseness to be checked by an otolaryngologist (an "ears, nose, and throat" specialist, or ENT). The ENT will:

• ask about the child's medical history
• listen for strain or breathiness in the voice
• do a diagnostic test to get an internal view of the voice box and check vocal cord function

The diagnostic test options include:

Flexible laryngoscopy. During this exam, a tiny, flexible fiber-optic tube with a camera attached to the end (called a scope) is passed through a nostril and into the throat. It gives a magnified view of the larynx. Kids are asked to speak, sing, sniff, cough, and make other sounds that make the vocal cords vibrate. Movements are recorded on a computer monitor so that specialists can analyze them later.

Rigid laryngoscopy. This can be done in the office for older kids, but very young children and others who can't tolerate a flexible laryngoscopy will have this test in an operating room under general anesthesia. The rigid scope passes 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 an 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. This makes it easier for doctors to determine the frequency of movement. Because individual vibrations are too fast for the naked eye to see, the strobe technology projects the vibrations in slow motion.

How Is Chronic Hoarseness Treated?

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 involves:

• treating any medical conditions (like GER) that aggravate vocal problems
• changing behaviors that distress 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 hydrated throughout the day
• avoiding caffeinated beverages, like soda, which dry out the vocal cords

It might be hard for kids with established bad habits — like talking loudly when they're excited or clearing their throats when they're nervous — to make changes. The first step is to make kids aware of the behavior and see how often they do it.

Older kids might learn to keep track of how often they engage in the behavior (perhaps keeping notes in a diary), which many do without realizing. Then they can practice the skills they've learned in therapy when at home, at school, and spending time with friends.

How Can Parents Help?

Parents can 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 talk to them. Promote quiet times (perhaps for half an hour each day) and using an "inside voice" when indoors.

Reward systems that encourage these new behaviors can help elementary school-age kids succeed. Offer stickers, tokens, extra TV time, a later bedtime, or similar "prizes" to get kids on board with the new, healthier habits.