Voice & Speech Conditions

Voice and speech conditions that can affect children and adolescents include:

Voice disorders. Voice disorders can include hoarseness, vocal fatigue, raspiness, periodic loss of voice or inappropriate pitch or loudness. Most voice disorders result from straining the voice in some way, such as frequent yelling or shouting, speaking too low or high or chronic throat clearing. Symptoms of voice disorders include:

• Hoarseness, raspiness or strain of the voice on a daily, weekly or otherwise frequent basis
• Hoarseness or intermittent voice loss during or after sports, cheering, shouting, singing or camp
• Deeper (lower) voice than others of the same age, making the child seem older
• Straining to reach the higher notes when singing
• Laryngitis-like symptoms, lingering well after a cold or upper respiratory infection has passed

Speech disorders. Common speech disorders include motor speech disorders, such as childhood apraxia of speech (CAS) and dysarthria, and stuttering. CAS occurs when a child’s brain has problems moving the body parts that are needed for speech, such as the lips, jaw and tongue. A child knows what he or she wants to say, but the brain has difficulty coordinating the muscle movements necessary to get out the words. Symptoms of CAS include:

• Inconsistent sound errors that are not the result of immaturity
• Understanding language much better than he or she can talk
• Appearing to be groping when attempting to produce sounds or coordinate the lips, tongue and jaw for purposeful movement
• Difficulty clearly saying longer words or phrases than shorter ones
• Difficulties being understood, especially for an unfamiliar listener
• Speech is choppy or monotonous, or emphasis is placed on the wrong syllable or word

Dysarthria occurs when a child has difficulty moving the muscles required for speech, including the lips, tongue, vocal folds and diaphragm. This condition is caused by damage to the brain either at birth or later by a condition such as cerebral palsy or muscular dystrophy. The symptoms of dysarthria include:

• Slurred, choppy or mumbled speech that may be difficult to understand
• Slow rate of speech
• Rapid rate of speech with a mumbled quality
• Limited tongue, lip and jaw movement
• Abnormal pitch and rhythm when speaking

Stuttering occurs when a child’s speech is characterized by interruptions known as disfluencies. In most cases, stuttering impacts at least some of a child’s daily activities. The symptoms of stuttering include:

• Partial-word repetition. This is when a child has difficulty moving from one letter in a word to the remaining sounds in a word and thus repeats the same sound two or more times.
• Sound prolongation. This is when a child has difficulty moving from the first sound in a word to the remaining sounds in a word and thus extends the first sound.
• A series of interjections. This is when a child expects to have some difficulty joining words within a sentence and thus uses filler words such as “um” to smooth the transition.

Juvenile-onset recurrent respiratory papillomatosis. Juvenile-onset recurrent respiratory papillomatosis (RRP) is a rare disorder in which a child develops small, wart-like growths (papillomas) in the respiratory tract. Papillomas can develop anywhere along the tract but most often grow in the larynx and the vocal folds. These benign growths can cause severe, even life-threatening airway obstruction and respiratory complications. RRP is caused by the human papillomavirus (HPV) infection. The symptoms of recurrent respiratory papillomatosis include:

• Hoarseness of the throat that may become progressively worse
• Labored, noisy breathing
• Difficulty speaking or swallowing
• Loss of voice
• Chronic cough
• Shortness of breath or difficulty breathing
• Choking episodes

Vocal fold (cord) paralysis or vocal fold (cord) paresis. Vocal fold paralysis occurs due to a nerve problem, a muscle problem or a fixation of the cricoarytenoid joint, which results in the paralysis of the vocal fold (cord) muscles. Paralysis is the total interruption of nerve impulse, resulting in no movement; paresis is the partial interruption of nerve impulse, resulting in weak or abnormal movement of laryngeal muscles. The symptoms of vocal fold paralysis may include:

• Breathy quality to the voice
• Hoarseness
• Noisy breathing
• Loss of vocal pitch
• Choking or coughing while swallowing food, drink or saliva
• Needing to take frequent breaths while speaking
• Inability to speak loudly
• Loss of the gag reflex
• Ineffective coughing
• Frequent throat clearing

Vocal fold (cord) webs. Vocal fold webs occur when thin connections form across the front portion of the vocal folds. These webs can either be congenital (present at birth) or caused by trauma, such as previous vocal surgeries or intubation. Small vocal fold webs may not bother a child at all. Larger webs may block airflow and affect the child’s ability to speak normally or breathe adequately. The primary symptoms of vocal fold webs include difficulty breathing or speaking normally.

Diagnosis of Voice & Speech Conditions

Doctors at Riley at IU Health make a diagnosis by first narrowing down the likely cause of your child's symptoms. The exams and tests used will depend on which condition the doctor suspects:

Voice disorder. If the doctor suspects your child has a voice disorder, the doctor will begin by thoroughly examining your child’s throat and voice box. The doctor will likely ask you and your child questions about when his or her voice becomes hoarse or raspy.

Childhood apraxia of speech. If your child’s doctor suspects he or she has childhood apraxia of speech (CAS), the doctor will likely recommend assessment by a speech-language pathologist (SLP). The SLP will perform one or more of the following tests to diagnose CAS:

• Oral-motor assessment. In this type of test, the speech-language pathologist assesses your child for signs of weakness or low muscle tone in the lips, jaw and tongue. The SLP will determine how well your child can coordinate the movement of his or her mouth.
• Melody of speech assessment. In this type of test, the SLP will listen to your child to ensure that he or she is able to appropriately stress syllables in words and words in sentences. The SLP will determine whether your child correctly uses pitch, pauses to mark different types of sentences and pauses to mark off different portions of the sentence.
• Speech sound assessment. In this type of test, the SLP will evaluate your child’s vowel and consonant sounds. The SLP will check how well your child says individual sounds and sound combinations.

Dysarthria. If your child’s doctor suspects he or she has dysarthria, the doctor will likely recommend assessment by a speech-language pathologist (SLP). The SLP will examine your child’s lip, tongue and facial movements as well as analyze the breath support for speech and voice quality.

Stuttering. If your child’s doctor suspects he or she has a stuttering condition, the doctor will likely recommend assessment by a speech-language pathologist (SLP). The SLP will analyze the frequency and severity of your child’s speech disfluencies as well as how he or she responds to and copes with these occurrences.

Juvenile-onset RRP. Juvenile-onset RRP is diagnosed using a detailed patient history, a thorough exam of the papillomas and specialized tests such as an indirect or direct laryngoscopy, which allows the doctor to closely examine the back of the throat.

Vocal fold (cord) paralysis. If your child’s doctor suspects he or she has vocal fold paralysis or vocal fold paresis, the doctor may run one or more of the following tests to diagnose the condition:

• Laryngoscopy. The doctor will examine your child’s vocal folds using a mirror or a thin, flexible tube (endoscope) in order to determine the movement and position of the vocal folds and whether one or both vocal folds are affected.
• Laryngeal electromyography. The doctor inserts tiny needles into your child’s vocal fold muscles through the skin of the neck in order to measure the electric currents in the vocal box muscles. This procedure is performed in the operating room under anesthesia.
• Blood tests. Your child’s doctor may order a blood test to help determine the cause of the paralysis.
• Imaging tests. Imaging tests such as X-ray, magnetic resonance imaging (MRI) and computed tomography (CT) can also help to identify the cause of your child’s vocal fold paralysis.

Vocal fold (cord) webs. If your child’s doctor suspects he or she has vocal fold webs, the doctor may recommend a laryngoscopy to determine the size and extent of the web structure.