DISCUSSION:
This study aimed to measure the rate of hoarseness among school-aged
children. In our study, we found that the prevalence of hoarseness was
7.5%, which is within the same range reported in the literature as
6-23%.4 Dobres et al found in their study on the
description of laryngeal pathologies in children with a sample size of
731 that the prevalence was more in males than in females, which was
similar to the findings of Kallvik et al in their study on the
prevalence of hoarseness in school-aged children with a sample size of
217.7,19 Children have a lower amount of elastin and
their vocal fold is less stable than in adults who have a significant
amount of elastin and collagen which provide more stability and provide
the elastic propriety of the vocal folds. Consequently, the vocal fold
of children with recurrent voice misuse vibrate more forcefully because
of a lack of elastic proprieties, putting them at a higher risk of
injury compared to adults,20 21 22hence that might account for the high rate of hoarseness in children.
In our study there was not a significant difference in the prevalence of
hoarseness according to gender, though it was found to be higher in
females than in males, which is similar to the prevalence in
adults.3 It is suggested that the impact of gender on
the voice is not significant in early childhood until the period when
each gender acquires his or her specific voice tone and pattern as well
as the social specific behavior of each
gender.19,23,24
Concerning the possible risk factors of hoarseness, we found that a
history of excessive crying during infancy was a possible factor
associated with current hoarseness in our study. Kallvik et al reported
a similar finding, whereby a history of heavy voice use during infancy
was significantly associated with current voice quality, especially
among females.19 Moreover, we found that a previous
history of hoarseness was significantly associated with current
hoarseness. Continued voice misuse in children and lack of education in
voice therapy might keep them at high risk of repeated voice disorders.
In our study, we found that letter articulation problems, or what is
known as phonation disorder, was an associated risk factor of hoarseness
in children. The exact reason is unknown but it might be due to the fact
that a child with a problem in letter articulation will try hard to
articulate the letters correctly, putting his voice in a repeated
tension along with a misuse of his voice, eventually leading to voice
disorders. Furthermore, letter articulation issues might be a symptom of
hidden underlying structural abnormalities such as a cleft palate or
neurological disorders.25 Additionally, in our study
we found that stuttering was another possible risk factor for
hoarseness. Stuttering or dysfluency is a type of speech disorder that
prevents an individual from speaking fluently. As a result, a stutterer
will repeat words, sounds, sentences, or take sudden involuntary breaks,
which might lead to abnormal physical and emotional behaviors as the
speaker struggles to end a particular sentence.26Stuttering can be developmental, which is the most common type, or
acquired secondary to brain injury or emotional
trauma.27,28 Salihović et al studied voice
characteristics in stuttering children in their case-control
experimental study and they found that the abnormal functioning of the
larynx and high muscular tension as well as subglottic pressure with
lack of coordination and control of respiratory muscles and laryngeal
muscles all lead to voice disorders.29 Children who
stutter were found to be at high risk of developing social anxiety, low
self-esteem, and a decreased quality of life in the
future.30,31 In our study, parents of children with
hoarseness reported that their child’s educational outcome was affected
by hoarseness; they also reported that their child felt inferior to
other children and they were bothered by their voices. In this regard,
early diagnosis of stuttering is important as it can have very promising
outcomes with early interventions.32 Hence, early
identification and referral to a speech language pathologist is required
and suggested to parents.
The LPR is an inflammatory reaction caused by the backflow of gastric
acid, which leads to laryngitis and pharyngitis.33 We
found that those having symptoms suggesting LPR (RSI > 13)
had a four-fold increased risk of hoarseness. Block et al found in their
study on the role of LPR in children with hoarseness in a sample size of
337 participants that 47% of the children who presented with the main
complaint of hoarseness were diagnosed with LPR and 68% of patients
showed improvement in hoarseness after initiating anti-reflux
management.18 Moreover, Gumpert et al found in their
study that 90% of children with hoarseness had endoscopic signs of
LPR.34 Carr et al described the endoscopic findings of
LPR in their study as: lingual tonsillar hyperplasia, postglottic edema,
and arytenoid edema.35 Remarkably, the study of Block
et al found that 48% of patients diagnosed with LPR had no cough or
throat clearing, which are the most common symptoms seen in children
with LPR. Hence, hoarseness in children is an important key to
diagnosing LPR.18 Most studies in the literature
correlate the endoscopic finding of LPR with subjective complaints of
hoarseness i.e. there is no acoustic voice analysis for hoarseness with
an objective assessment. However, Niedzielska et al conducted a study on
11 participants in whom reflux disease was confirmed with pH-metric
assessment in the esophagus as well as objective voice measurements with
lupolaryngoscopy, stroboscopy, and acoustic voice analysis (jitter,
shimmer, harmonic/noise ratio, and phonation time).36They confirmed the correlation between an inflammatory changed larynx
and voice disorders.
To our knowledge, our study is the first large-scale study that has
examined hoarseness in school-aged children in Saudi Arabia and
investigated its related risk factors. However, our study had some
limitations, including the subjective nature of the tools used (RSI and
CVHI-10-P) and the lack of appropriate objective clinical and endoscopic
evaluations of the larynx and head and neck region to confirm the
diagnosis. Furthermore, one cannot solely depend on RSI for the
diagnosis of LPR and more appropriate diagnostic tools such as an
assessment of the patient’s pH levels are needed.37However, clinical assessment was offered to the children of interested
parents for further evaluation of their child’s voice, but these
findings were not included in the current study. Using a cross-sectional
design limited the ability to identify the temporal sequences of events,
thus causality of identified risk factors could not be established,
especially considering the retrospective nature of the questionnaire and
the possibility of recall bias and measurement error. However, due to
the aim of covering a large sample of schools (n= 21) in the eastern
province of the Kingdom, parents were contacted by their child’s class
teacher via an online self-completed questionnaire that, unfortunately,
resulted in a limited response rate from the parents, and consequently a
possibility of selection bias. However, the resulting prevalence and
risk estimations of associated factors of hoarseness in our study were
comparable to those reported in the literature and therefore our results
could be considered feasible.
In fact, the limited response rate might indicate the possibility of a
low level of parental awareness regarding voice disorders in children
and the need for further parental education to raise their awareness in
the future.