Pediatric Voice Disorders

Pediatric Voice - Little Larynxes, Big Sounds

• Pediatric vs. Adult Larynx:
  • Size: Smaller in all dimensions.
  • Position: Higher (📌 C3-C4 child vs. C5-C6 adult).
  • Cartilage: Softer, less calcified, more prone to collapse.
  • Subglottic Shape: Funnel-shaped (narrowest at cricoid ring), unlike adult cylindrical shape. This makes children prone to croup.
• Common Symptoms:
  • Hoarseness: Most frequent.
  • Stridor: High-pitched; inspiratory, expiratory, or biphasic.
  • Weak cry or altered cry.
  • Aphonia (loss of voice).
  • Vocal fatigue with use.

, cartilage consistency, and subglottic shape (funnel vs cylinder))

⭐ Laryngomalacia is the most common congenital laryngeal anomaly and cause of stridor in infants.

Congenital Quirks - Built-In Voice Woes

• Laryngomalacia: Commonest cause of infant stridor. Inspiratory stridor, omega-shaped epiglottis.
  • Type I: Arytenoid prolapse.

    ⭐ Type I Laryngomalacia (prolapse of arytenoids) is the most common type.

  • Type II: Short aryepiglottic folds.
  • Type III: Epiglottic collapse.

![Omega-shaped epiglottis and tall aryepiglottic folds](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/ENT_Phoniatrics_and_Voice_Disorders_Pediatric_Voice_Disorders/165d3d5f-e072-4667-a5f2-e47362c09274.jpg)

• Congenital Vocal Fold Paralysis:
  • Unilateral: Weak cry, aspiration. More common.
  • Bilateral: Stridor, airway distress. Causes: birth trauma, CNS.
• Laryngeal Webs: Anterior. Hoarseness/aphonia. Severity: Cohen's classification (Type I-IV).
• Subglottic Stenosis: Congenital (cartilaginous/membranous) or acquired. Biphasic stridor. Cotton-Myer Grade I-IV.
• Laryngeal Cysts:
  • Saccular: From saccule; airway obstruction risk.
  • Ductal: Mucous retention on TVF.
• Sulcus Vocalis: Groove on VF edge; hoarse, breathy voice.

Acquired Issues - Voice Under Pressure

-   Cause: HPV **6** & **11**.
-   Lesions: Multiple, wart-like lesions on larynx/airway.
-   Tx: Surgery ± Cidofovir.

• Functional Dysphonia
  • Cause: Psychogenic or Muscle Tension Dysphonia (MTD).
  • Voice: Strained, breathy, or aphonia; no organic lesion.
• Puberphonia (Mutational Falsetto)
  • Issue: Persistently high-pitched male voice after puberty (falsetto).
  • Tx: Voice therapy.

⭐ Vocal nodules are the most common cause of persistent hoarseness in school-aged children.

Dx & Rx - Tuning Tiny Tones

• Diagnosis (Dx):

  • History: Crucial details: onset, nature of cry/voice, feeding difficulties, respiratory distress.
  • Examination:
    • Perceptual Voice Evaluation: GRBAS/CAPE-V scales.
    • Laryngeal Visualization:
      • Flexible Nasopharyngolaryngoscopy (FNPL): Primary diagnostic tool.

        ⭐ Flexible nasopharyngolaryngoscopy is the primary diagnostic tool for visualizing laryngeal pathology in children.

      • Rigid Laryngoscopy: Detailed views, often under GA.
      • Stroboscopy: Assesses vocal fold vibration if cooperation allows.
    • Objective Assessment: Acoustic analysis (F0, jitter, shimmer), aerodynamic measures (MPT).

• Treatment (Rx) Strategy:

*   **Management Pillars:**
    - **Voice Therapy:** Cornerstone for vocal nodules, functional disorders; age-specific techniques.
    - **Medical:** GERD treatment; Antivirals for RRP (e.g., Cidofovir).
    - **Surgical (MLS):** For congenital webs, cysts, severe RRP, or failed conservative treatment.

High‑Yield Points - ⚡ Biggest Takeaways

• Laryngomalacia: Most common cause of infantile stridor; typically inspiratory.
• Vocal Nodules: Most frequent cause of chronic hoarseness in children; due to voice abuse.
• RRP (Recurrent Respiratory Papillomatosis): Caused by HPV 6 & 11; hoarseness, stridor.
• Subglottic Stenosis: Congenital or acquired; presents with biphasic stridor.
• Vocal Cord Paralysis: Unilateral leads to weak cry/hoarseness; bilateral causes stridor/respiratory distress.
• Laryngeal Webs: Congenital; cause hoarseness/aphonia from birth.
• Voice Therapy: Key for functional voice disorders like nodules.