Jack is a four-year-old whom I recently saw for his pre-K examination. He is a very outgoing little guy with quite a personality. First of all, he looks like Dennis the Menace with a cowlick and freckles. He carries himself like someone much older than his mere four years. He is quite a conversationalist, and I was struck how mature and comfortable he was in talking with me.
When asked how old he was Jack proceeded to tell me about his birthday party. I was told about the birthday cake, all the friends that were there as well as the many gifts he received. Then I asked him if he had enjoyed the fireworks for the Fourth of July. He gave me a detailed account of the display, and re-enacted the event with life-like sound effects. Then he asked me what I did for the Fourth.
Turning to mom I asked about his general health. We went through the review of systems which is a checklist encompassing all of the organ systems. It wasn’t long before I realized that mom’s input wasn’t necessary. Jack answered almost all of the questions in a mature, matter of fact manner. It was cute and humorous at times to hear him talk about his diet, bowel habits and sleep patterns using big words—some of them not quite accurately. But I did get the picture. I would look at mom, and she would nod or shake her head to corroborate what he was saying. Most of his information was spot on.
What I did notice was that his voice was a bit raspy and hoarse, and at times it would crack. Mom indicated that this had been going on for at least a few months. She said that it was cute at first. His older cousins would call him “Froggy”. But she was concerned that it had been going on too long and was worried that it might be something more serious. “I was glad that he had his physical at this time because I wanted to bring this up with you.”
When asked if it was persistent or would it come and go, she said that it started some time ago and has been persistent, although it has not gotten worse. Did he have any stridor, or noise when he breathes in? She answered no. He has been perfectly healthy since his physical a year ago. She added, “His voice is just so raspy. He sleeps just fine and doesn’t snore or have any problems playing or sleeping.”
She smiled when I asked if he is a particularly loud talker. “He has three older sibs and has to compete to get the floor. So, yes, he is a very loud talker. And when he gets center stage he won’t give it up but goes on and on…as you can very well see.”
I learned that he plays hard and is “all boy”. When he goes to his brother’s baseball games he is the number one cheerleader. Playing with his friends, you can hear him re-enact the monster growls or explosions two rooms away.
His diagnosis was becoming much clearer. It was believed that Jack had vocal cord nodules. This is not serious but I was going to have him see an ear-nose-throat specialist (ENT) to confirm the diagnosis so that we could set up a treatment plan.
Vocal cord nodules are not uncommon in the pediatric population and are usually caused by voice misuse or abuse. The vocal cords undergo excessive wear and tear by this voice misuse which causes them to stretch too far or to constantly rub together. This leads to irritation and causes a fleshy growth, much like a blister, that eventually becomes callused and forms a nodule. When visualized by the ENT doctor, they usually occur on each vocal cord, opposite each other or facing each other. These nodules are not cancerous and are not dangerous, but they are not likely to resolve on their own without the proper intervention.
The symptoms of nodules are hoarseness, breathiness, voice breaks whereby the voice cuts out briefly, changes in pitch or a strained voice. The most common causes are talking too long or loud, yelling excessively or having frequent tantrums with screaming. Also making extreme sound effects when playing or frequent throat clearing can be the cause. There are some associated conditions that may exacerbate the symptoms. These include chronic allergies with persistent post-nasal drip and gastro-esophageal reflux with acid refluxing into the back of the throat, irritating the vocal cords. When I see a patient with possible nodules I direct them to the ENT who can visualize the vocal cords and confirm the diagnosis making sure that this is not something else such as a vocal cord paralysis or another structural problem. Once a diagnosis of nodules is made the treatment is having the patient see a speech pathologist. He can work with him teaching him the tools and techniques to use his voice properly. Mom can be given exercises that he can do at home as well. The prognosis is excellent.
The ENT called me after seeing Jack and said, “Boy, what a neat little kid. He had impressive nodules and nothing else going on. I made an appointment for him to see the speech pathologist. I don’t need to see him back unless this doesn’t resolve as expected…and by the way. He asked me what I did for the Fourth of July. Then he proceeded to re-enact every explosion with intense sound effects.”