Clinical Analysis of Hoarseness in Children as Seen in Otorhinolaryngology Department of a Tertiary Health Institution in North-West , Nigeria

Normal phonation is produced in the larynx by the blast of pulmonic air stream that vibrates the vocal cords. Hoarseness reflects changes in the structure or function of the vocal cords. Objective: This is to describe the clinical profile of hoarseness in children and aetiological factors in a tertiary health institution. Methodology: This is a retrospective eight-year (2006-2013) study of clinical records of patients with hoarseness as their main symptom seen in the ENT department of the Usmanu Danfodiyo University Teaching Hospital Sokoto. Results: Fifty-two children with hoarseness were studied. Thirty three (63.5%) were males, while 19 (36.5) were female with a male: female ratio of 1.7:1. The age range was 1 13 years with a mean age of 5.1 years. Age group 4 7 years (38.5%) were observed to be more affected with duration of hoarseness ranging from 1 day to 5 years. RRP 23 (44.2%) was the most common aetiology of hoarseness followed by foreign body 15 (28.8%) and Acute Laryngeal infections 9 (17.3%). Tracheostomy was done in 29 (55.8%) of patients. Two patients died post operatively due to improper tracheostomy tube care in the ward. Conclusion: With delayed presentation and its attendant grave sequelae, it has become imperative that persistent hoarseness in children lasting more than three weeks should be endoscopically evaluated by an otorhinolaryngologist.


Introduction
The term Voice is the acoustic outputs from the Larynx that are characterized by their dependence on Vocal cord vibratory inputs [1]- [4].The quality of the voice is wholly dependent upon the vibratory characteristics of the laryngeal structure [1].Hoarseness is a Disorder of Voice simply defined as a perceived rough, harsh or breathy quality of the Voice [3].The disorder reflects changes in the structure and function of the vocal cords, mostly following laryngeal inflammation, trauma, neoplastic lesions or motility disorder of the vocal cords [2] [3].
There is limited information on the prevalence of Voice disorder particularly the pediatric population.The prevalence of hoarseness in children ranges from 4% -23% in the United State of America [3].
Hoarseness in children has varied presentation depending on the etiology and may be transient just like in the adult when due to acute inflammation of the larynx [4].The tendency of misdiagnosis contributes to the delayed in presentation to otorhinolaryngologist.In our region, medical attention is being sought for when complication of upper airway obstruction has ensued.
The study details the clinical presentation of hoarseness in children in our center and highlights challenges in management.

Materials and Method
This is a retrospective study of clinical records of patients who primarily presented or were referred to the Ear, Nose and Throat department of the Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria with Hoarseness as their main symptom over an Eight-year period (1 st January 2006 to 31 st December 2013).Data extracted from the retrieved health information records of these patients included-biodata, history of difficulty in breathing, onset and duration of hoarseness, history of previous head and neck trauma or surgery and relevant drug medication.There are detail records of radiological and operative findings, and histological diagnosis.Endoscopic laryngeal evaluation was carried out in all patients, while tissue biopsy, and foreign body removal or laryngeal repair were done under general anaesthesia to some patients.The data was analyzed using simple descriptive epidemiology, tables and figures.

Results
A total of 52 children with hoarseness were analyzed.Thirty three (63.5%)were males, while 19 (36.5) were female with a Male: female ratio of 1.7:1.The age range was 1 month -13 years with a mean age of 5.1 years.Age group 4 -7 years (38.5%) were observed to be more affected with a duration of hoarseness ranging from 1 day to 5 years.
Recurrent respiratory papilomatosis 23 (44.2%) was the commonest aetiology of hoarseness followed by Laryngeal foreign bodies 15 (28.8%) and 9 (17.3%)Acute laryngeal infections are shown in Table 1.Tracheostomy was done in 29 (55.8%) of patients (Figure 1).Of these, 15 (28.8%) with severe upper airway obstruction at presentation and subsequently had emergency tracheostomy.The other identified causes of hoarseness in this study were trauma 3 (5.8%)and vocal cord nodules 2 (3.9%).Two patients died post operatively due to improper tracheostomy tube care in the ward while decanulation and follow up of the 27 (51.9%)patients were uneventful.

Discussion
The infantile larynx is proportionally smaller than that of the adult compared to body size and lies opposite the third to sixth cervical vertebrate [1]- [3].Also being a little high in position than in men [5].Laryngeal pathology in children more frequently results in the development of upper airway obstruction requiring meticulous clinical evaluation for possible etiology.Hoarseness in children however, depicts laryngeal pathology.In this study, prevalence of hoarseness was observed to be higher in males with a ratio of M:F 1.7:1 and age group 4 -7 years being commonly affected which agrees with the findings of similar studies in sub-Saharan Africa [4].The leading cause of childhood hoarseness in our study is recurrent respiratory papilomatosis (Table 1 & Table 2).This condition has been reported to be the most common benign tumor of the larynx in children [6] [7].It is a potentially devastating condition with significant morbidity.Human papiloma virus (HPV) type 6 and 11 is responsible for the development of RRP.This virus has been associated with vertical transmission from mother to child during vaginal delivery from an infected mother [8] [9].RRP affected 23 (44.2%) of our study population Acute laryngeal infections: 9 (17.3%) and frequently misdiagnosed as asthma in our region.This is at variance with studies in the developed world, where laryngo-pharyngeal reflux is now the leading cause of childhood hoarseness [10].Foreign bodies are the second most common cause of hoarseness constituting 28.8% in our study (Table 1 & Table 2).Tracheostomy was done in five of these patients pre-operatively due to prolonged impaction resulting in upper airway obstruction.The unusual foreign body in our study was in a nine months old boy with impacted triangular piece of glass in the larynx (Figure 2(a) & Figure 2(b)).Endoscopic removal of the foreign bodies under general anaesthesia was achieved in all.Children aged 0 -3 years were commonly affected which is in consonance with earlier studies in sub-Saharan Africa [4].This is because children in this age group are very inquisitive and still exploring objects in their environment placing them in their mouth more frequently [11]- [13].This underscores the need for awareness and close monitoring of these children by their parents or caregivers.Acute laryngeal infections in our series were, Croup, Epiglottitis and retropharyngeal abscess.There were no records of immunizable diseases in our current report as in similar studies in the region [4].This is a remarkable improvement in the ongoing health education on Vaccines immunization against Childhood diseases.All had remarkable improvement after doses of broad-spectrum penicillin based antibiotics.The retropharyngeal abscess which commonly followed rupture of retropharyngeal lymph node was drained under general anaesthesia.Plain radiographs of the soft tissue neck are an invaluable tool in the diagnosis of this condition.
The aggressiveness of children in their natural habitat makes them prone to trauma and this accounted for 5.8% of our study population.
Hoarseness following vocal cord nodules (the most common cause of dysphonia in children) [4] is less common and is observed in 3.9% of our patients and similar to previous reports in the region [4] [14].This could be the less vigorous use of the voice by children.
Patients with laryngeal pathology requiring a tracheostomy following laryngeal obstruction accounted for 55.8% of our study population (Figure 1).The high frequency is in consonance with findings in earlier studies [15] [16] and could be attributed to late presentation to otorhinolaryngologist.

Conclusions
Recurrent respiratory papillomatosis is the leading cause of hoarseness in children in sub-Saharan Africa, hence the need for other adjuvant methods of treatment to achieve complete remission is recommended.
Early presentation of a child with hoarseness will improve the quality of life.We also recommend that persis-

Figure 2 .
Figure 2. (a) X-ray Soft tissue neck, Lateral view showing an impacted radiopaque glass foreign body in the larynx of an infant (arrow).(b) Foreign body (glass) removed after direct laryngoscopy under general anaesthesia.

Table 1 .
Age distribution of etiology of hoarseness.

Table 2 .
Sex distribution of laryngeal pathology.