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Introduction
Impairment of voice quality is common in children. The term dysphonia is used to describe disorders of voice generation at laryngeal level, as opposed to disorders of vocal resonance (involving the nose and nasopharynx) and disorders of articulation (involving the oral cavity). Dysphonia can encompass a range of situations in which the child or their parents are dissatisfied with the child's quality of voice, often described as 'hoarse', 'husky', 'weak', etc. In a large community study in Avon, UK,1 11 per cent of 7389 children aged eight years were reported by their parents to be hoarse. Dysphonia was more common in boys and in those with older siblings. It is unlikely that all these children's parents would seek hospital referral for investigation and treatment; however, enough do for dysphonia to be a common presentation in paediatric otolaryngology practice.
Practice varies considerably in what, if any, investigations are performed and how the condition is managed in otolaryngology clinics. Although childhood dysphonia is mostly due to non-serious causes such as voice misuse and consequent vocal fold nodules,2,3 very serious pathology such as papillomatosis or malignancy occasionally needs to be excluded, and treatable congenital anomalies such as webs and cysts can be missed. The role of laryngopharyngeal reflux (LPR) in dysphonia has been increasingly discussed in recent years.4-6 Although the optimal means of assessment is still a subject of debate (methods include history alone, endoscopic examination, contrast swallow, single- and dual-channel pH studies, and intraluminal impedance measurement), the proportion of dysphonic children diagnosed with LPR seems to depend on how aggressively the diagnosis is pursued. It is not known whether Helicobacter pylori has a role in paediatric voice disorders, but there is some preliminary evidence from adults suggesting that H pylori may have a role in patients with vocal fold polyps.7
Guidelines for the management of paediatric dysphonia have been suggested, but there is currently no general consensus on the extent of investigation required. In one US study,6 most, but not all, children underwent endoscopic examination of the larynx. Of those who did, 36 per cent had LPR alone, 29 per cent had vocal fold nodules alone, and 20 per cent...