All kids strain their voices every now and then: cheering for the home team at
a ballgame; belting out a favorite song in the shower; calling out to friends on the
Most of the time, this doesn't do any real harm to the vocal cords, the delicate
bands of tissue in the larynx, or voice box. But chronic misuse of the vocal cords
— such as repetitive screaming, yelling, or using the voice in an unnatural
way — can lead to hoarseness. When this happens, the voice crackles and sounds
rough, raspy, or breathy.
Sounding hoarse for a few hours or the day after a big game is probably nothing
to worry about, and usually resolves on its own. But chronic hoarseness that lasts
for days, weeks, or even months needs to be checked out by a doctor. Speech therapy
may be needed to get the vocal cords back into perfect pitch.
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
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 long 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)
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 do a diagnostic
test that provides an internal view of the voice box and vocal cord function.
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 to let doctors 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
Rigid laryngoscopy. This can be done in the office for older
kids, but very young children and others who cannot tolerate a flexible laryngoscopy
will have 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 see,
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
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 hard to make changes
in the beginning. 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.
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 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 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.