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Hoarseness (Dysphonia) in a 2-Year-Old Child - Causes & Management

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Differential Diagnosis (Causes of Long-Duration Hoarseness at Age 2)

1. Recurrent Respiratory Papillomatosis (RRP / JORRP) - HIGH PRIORITY

• Caused by HPV types 6 and 11, transmitted vertically during vaginal delivery
• Peak onset: ages 2-4 years
• HPV 11 causes more aggressive disease than HPV 6
• Prevalence: ~4 per 100,000 children
• Hoarseness is the cardinal symptom, often accompanied by stridor, chronic cough, recurrent respiratory infections, or failure to thrive
• Can be misdiagnosed as asthma, laryngitis, or croup - delay in diagnosis can be up to 8 years
• Rarely, tracheal/bronchopulmonary spread; malignant transformation has been reported (~20 pediatric cases, all fatal)

2. Vocal Fold Nodules (Screamer's Nodules)

• Most common cause of chronic hoarseness in school-age children; can occur in toddlers with vocal overuse (excessive yelling, crying, screaming)
• Bilateral, symmetrical lesions at the junction of anterior 1/3 and posterior 2/3 of the vocal folds
• Associated with loud, boisterous vocal behavior

3. Laryngomalacia / Subglottic Pathology

• May be associated with hoarse or stridor-like voice quality

4. Vocal Fold Paralysis

• Can be congenital or result from prior surgery (cardiac, thoracic, neck), intubation, or neurological disease
• Causes a weak, breathy voice

5. Gastroesophageal Reflux Disease (GERD) / Laryngopharyngeal Reflux

• Acid irritation of the posterior larynx causes chronic inflammation
• Often coexists with other conditions

6. Congenital Laryngeal Lesions

• Laryngeal web, saccular cysts, subglottic stenosis

7. Hypothyroidism

• Rare but correctable metabolic cause

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Diagnostic Approach

Step 1 - Clinical Assessment

• Detailed history: onset, progression, stridor, dysphagia, feeding difficulties, respiratory distress, prior intubation, birth history, immunization status
• Character of hoarseness: breathy (paralysis) vs. rough/raspy (nodules) vs. gradual progression (papilloma)

Step 2 - Awake Nasolaryngoscopy (FIRST-LINE)

• Preferred method: awake flexible fibreoptic nasolaryngoscopy using an infant 2.2 mm or 2.7 mm endoscope
• Performed before any general anaesthetic if RRP is suspected - unexpected papillomas prolapsing into the glottis under GA represent a significant airway emergency
• Allows direct visualisation of vocal cord mobility, lesions, and subglottis

Step 3 - Further Investigations

• Imaging (CXR, CT neck/thorax if pulmonary spread suspected in RRP)
• Thyroid function tests if hypothyroidism suspected
• Reflux investigations if GERD suspected

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Management by Cause

A. Recurrent Respiratory Papillomatosis (RRP/JORRP)

• Spontaneous respiration without endotracheal intubation (preferred)
• Induction: IV propofol or inhalational sevoflurane in oxygen
• Topical 2% lidocaine to larynx
• Maintenance via nasopharyngeal airway (size appropriate to age)
• Meticulous haemostasis with topical epinephrine 1:10,000 on neurosurgical patties
• Post-op humidified oxygen
• GOR prophylaxis: H2-antagonist or PPI for 48 hours post-surgery (laryngeal mucosa breached)

• Total operations per patient can range from 2 to over 400 in severe JORRP - this is a disease of recurrence, not cure

• Quadrivalent/nonavalent HPV vaccines target HPV types 6 and 11
• Vaccination of adolescents and young adults is preventive
• Evidence suggests vaccination may reduce recurrence rate in established RRP - PMC review on hoarseness causes

B. Vocal Fold Nodules

• First-line: Watchful waiting + voice hygiene education
  • Educate parents: reduce yelling, screaming; model calm vocal behavior
  • Adequate hydration; avoid irritants (smoke, allergens)
• Voice therapy: Effective for children older than 2 years (AAFP guidelines recommend voice therapy); at 2 years old, indirect therapy (parent-focused behavior modification) is the primary approach
  • A 2024 prospective cohort study (PMID: 35082048) confirmed that indirect voice therapy improves vocal quality in children with vocal fold nodules
• Surgery (microlaryngoscopy with microsurgical excision): only if nodules persist despite voice therapy, cause significant airway impairment, or diagnosis is uncertain. Surgery should generally be deferred in young children as nodules frequently resolve spontaneously at puberty
• A 2024 study (PMID: 38101141) on surgical trends for vocal cord nodules in children found favorable outcomes but emphasized conservative management first

C. GERD / Laryngopharyngeal Reflux

• Lifestyle: upright positioning after feeds, small frequent meals, avoid acidic foods
• Pharmacologic: H2-antagonist or PPI in confirmed cases
• Refer to pediatric gastroenterology if refractory

D. Vocal Fold Paralysis

• Depends on cause: unilateral may spontaneously recover (especially post-intubation)
• Bilateral: airway management priority (possible tracheostomy)
• ENT + neurology + cardiology input as indicated
• Speech-language pathology support

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Key Management Principles Summary

1. Fibreoptic laryngoscopy is mandatory for any child with hoarseness lasting >4 weeks - do not assume benign cause
2. RRP must be excluded first in a 2-year-old - it is the age-specific red flag
3. Microdebrider is the gold standard surgical tool for RRP - better voice outcomes than CO2 laser
4. No surgery for vocal nodules as first line - voice therapy and observation preferred
5. Voice therapy is effective from age 2 - indirect (parent-directed) methods used at this age
6. GERD prophylaxis is important post-laryngeal surgery (H2-antagonist or PPI for 48 hrs)
7. Multi-disciplinary team: Pediatric ENT, speech-language pathologist, pediatric gastroenterology, and nursing

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🚨 EMERGENCY TREATMENT PLAN

Pediatric Severe Respiratory Distress + Dehydration

Patient: 2-year-old child | RR: 50/min | Intercostal/subcostal retractions | Clinically dehydrated

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STEP 0 - IMMEDIATE TRIAGE (First 60 seconds)

• Activate pediatric emergency team / call senior pediatrician NOW
• Place child in position of comfort (do not force to lie flat - may worsen distress)
• Do NOT separate from caregiver - reduces agitation and oxygen demand
• Do NOT perform painful procedures before oxygen is established

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STEP 1 - AIRWAY & BREATHING (Priority 1)

Assess Airway

• Is airway patent? Look for stridor, drooling, neck position (signs of epiglottitis/croup/foreign body)
• If stridor is present - suspect upper airway obstruction; do NOT examine throat blindly

Oxygen Supplementation - IMMEDIATE

• Target SpO2 ≥ 94% (WHO: minimum ≥ 90%)
• Attach pulse oximetry continuously
• Withhold oral feeds while in severe respiratory distress (aspiration risk)
• Allow humidified oxygen when possible

Signs of Impending Respiratory Failure (call ICU now if any present)

• SpO2 < 90% despite high-flow oxygen
• Grunting, head bobbing, cyanosis
• Altered consciousness / lethargy
• Recurrent apnoeic episodes
• Bradypnea or gasping

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STEP 2 - CIRCULATORY ACCESS & FLUID RESUSCITATION

Establish IV Access

• Insert large-bore IV cannula (or 2 lines if severely compromised)
• If IV access fails twice: consider intraosseous (IO) access
• Draw blood at time of insertion (see investigations below)

Fluid Resuscitation - WHO Plan C (Severe Dehydration)

WHO Plan C for children >12 months: 30 mL/kg in 30 minutes, then 70 mL/kg in 2.5 hours = total 100 mL/kg

• Reassess every 15-30 minutes during rapid infusion
• Once child can drink: start ORS at 5 mL/kg/hour alongside IV fluids
• Monitor for signs of fluid overload (especially in cardiac/renal disease)
• Check blood glucose immediately - treat hypoglycemia if glucose < 54 mg/dL (10% dextrose 2 mL/kg IV)

Maintenance Fluids (after resuscitation)

• Use 0.9% NaCl + 5% dextrose OR Ringer's Lactate for ongoing maintenance
• Holliday-Segar formula:
  • 2-year-old (~12 kg): 100 mL/kg for first 10 kg + 50 mL/kg for remaining 2 kg = 1100 mL/24 hours
  • Add estimated ongoing losses (vomiting, diarrhea, insensible losses from tachypnea)

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STEP 3 - MONITORING

• Pulse oximetry (continuous)
• Heart rate and respiratory rate (every 15 min initially)
• Blood pressure (every 30-60 min)
• Temperature
• Urine output (insert urinary catheter if needed) - target ≥ 1 mL/kg/hour
• Mental status / AVPU score
• Skin color, capillary refill time (CRT < 2 seconds = goal)
• Record on a pediatric early warning score chart (CEWT or similar)

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STEP 4 - INVESTIGATIONS

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STEP 5 - CAUSE-DIRECTED TREATMENT

Most Likely Diagnosis in a 2-Year-Old with RR 50 + Retractions + Dehydration:

1. Severe Community-Acquired Pneumonia (bacterial or viral) - most common
2. Bronchiolitis (if wheeze + RSV season)
3. Severe Croup (if inspiratory stridor present)
4. Sepsis (if hemodynamically unstable)
5. Foreign body aspiration (if sudden onset, asymmetric wheeze)

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A. ANTIBIOTICS (for suspected severe bacterial pneumonia)

• Add Cloxacillin 50 mg/kg/dose IV q6h, OR
• Switch to Ceftriaxone 50 mg/kg/dose IV once daily (third-generation cephalosporin as second line)

• Add Azithromycin 10 mg/kg on day 1, then 5 mg/kg once daily x 4 days

Note: In a 2-year-old with likely viral etiology (RSV, parainfluenza), antibiotics may be withheld if clinical picture is clearly viral - discuss with senior clinician.

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B. BRONCHOSPASM / WHEEZE (if present)

• Salbutamol (albuterol) nebulized: 0.15 mg/kg (min 1.25 mg) in 3 mL normal saline q20 min x 3 doses, then 1-4 hourly
• Ipratropium bromide nebulized: 0.25 mg q20 min x 3 doses (for moderate-severe wheeze)
• If no response: IV magnesium sulfate 25-50 mg/kg (max 2 g) over 20 minutes

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C. CROUP (if stridor present)

• Dexamethasone 0.6 mg/kg IM/PO single dose (max 10 mg)
• Nebulized adrenaline (epinephrine) 1:1000 - 0.5 mL/kg (max 5 mL) if severe stridor at rest
• Humidified oxygen
• Monitor for at least 2-4 hours after nebulized adrenaline (rebound effect)

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D. ANTIPYRETICS (if fever present)

• Paracetamol (acetaminophen) 15 mg/kg per dose PO/PR/IV q6 hours
• Do NOT give ibuprofen if dehydrated (renal risk)

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E. SUPPORTIVE MEASURES

• Nurse in semi-upright position (30-45 degrees) - reduces work of breathing
• Nasopharyngeal suctioning if secretions are thick/obstructing
• Humidified oxygen where available
• Nil by mouth while in severe respiratory distress
• Resume oral/nasogastric feeds as soon as respiratory distress stabilizes
• Zinc supplementation 20 mg/day x 10 days (WHO recommendation if diarrhea present)
• Avoid cough suppressants

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STEP 6 - ESCALATION CRITERIA (Consult ICU / PICU)

• SpO2 < 90% on FiO2 > 40% (face mask + reservoir bag)
• Ongoing hemodynamic shock despite 2-3 fluid boluses
• Altered consciousness (GCS drop, unresponsive to pain)
• Recurrent apneas or irregular breathing
• Rising PaCO2 on blood gas (respiratory fatigue)
• Intubation being considered
• No response to bronchodilators

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STEP 7 - ONGOING MONITORING & REASSESSMENT

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QUICK REFERENCE SUMMARY

AIRWAY     → O2 by nasal prongs/mask → target SpO2 ≥ 94%
BREATHING  → Position upright, no oral feeds, monitor RR continuously  
CIRCULATION → IV access → RL bolus 20 mL/kg x 15-20 min → reassess
FLUIDS     → WHO Plan C: 30 mL/kg/30 min then 70 mL/kg/2.5 hrs
GLUCOSE    → Check stat → treat if <54 mg/dL
ANTIBIOTICS → Ampicillin 50 mg/kg IV q6h + Gentamicin 7.5 mg/kg IV OD
FEVER      → Paracetamol 15 mg/kg q6h
MONITOR    → Pulse ox, HR, RR, BP, urine output, blood gas, CXR
ESCALATE   → PICU if SpO2 <90% on high-flow O2, shock, altered GCS

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