Infant Hoarseness: Causes and Management
Hoarseness in a newborn or infant is a red flag condition that mandates immediate consultation with an otolaryngologist, as it may signal serious underlying pathology including birth trauma, intracranial processes like Arnold-Chiari malformation, or mediastinal disease. 1
Immediate Action Required
Refer to otolaryngology immediately—do not observe or treat empirically. The American Academy of Otolaryngology-Head and Neck Surgery explicitly lists "hoarseness in a neonate" as a condition requiring urgent laryngoscopy regardless of duration. 1 This is not a "wait and see" situation.
Most Common Causes in Infants
The diagnostic landscape differs dramatically by age:
In Newborns and Young Infants (<6 months):
- Vocal cord paralysis is the leading cause, accounting for 50% of cases in newborns and 36.7% in infants under 6 months 2
- Congenital heart disease is present in nearly half (48.7%) of infants with vocal cord paralysis 2
- Birth trauma affecting the recurrent laryngeal nerve 1
- Cardiovocal syndrome from cardiac enlargement causing left recurrent laryngeal nerve traction 3
Across All Infant Age Groups:
- Vocal fold hypertrophy and hyperplasia (37.8% of persistent cases) 2
- Laryngeal hemangiomas (5.9%) 2
- Laryngeal webs and cysts (3.4%) 2
- Arnold-Chiari malformation or posterior fossa masses 1
- Mediastinal pathology compressing the recurrent laryngeal nerve 1
Critical Diagnostic Pathway
Step 1: Immediate Otolaryngology Referral
The infant requires laryngoscopy by an otolaryngologist to visualize the vocal folds and laryngeal structures. 1 This is non-negotiable and should occur within days, not weeks. 4
Step 2: Targeted History
While awaiting specialist evaluation, document:
- Birth history: Traumatic delivery, prolonged labor, forceps use 1
- Cardiac symptoms: Cyanosis, feeding difficulties, failure to thrive, tachypnea 3
- Neurologic signs: Abnormal tone, swallowing difficulties, aspiration with feeds 1
- Respiratory distress or stridor: Indicates potential airway compromise 4, 5
- Recent intubation or surgery: Even brief intubation can cause vocal fold injury 1
Step 3: Additional Workup Based on Laryngoscopy
Once laryngoscopy identifies the pathology:
- If vocal cord paralysis is found: Obtain cardiac ultrasonography (nearly 50% have congenital heart disease) and CT neck/chest with contrast to evaluate the entire course of the recurrent laryngeal nerve from brainstem to aorticopulmonary window 2, 6, 3
- If left vocal cord paralysis specifically: Must image down to the aorticopulmonary window, as left recurrent laryngeal nerve loops under the aortic arch 6
- If intracranial pathology suspected: MRI brain to evaluate for Arnold-Chiari malformation or posterior fossa mass 1
Treatment Approach
Treatment is entirely dependent on the underlying cause identified at laryngoscopy:
- Vocal cord paralysis from cardiac disease: May resolve after surgical repair of the cardiac defect 3
- Laryngeal hemangiomas: May require medical therapy or surgical intervention 2
- Vocal fold nodules/polyps: Rare in infants but may require observation or surgery 2
- Structural anomalies: May require surgical correction 2
Critical Pitfalls to Avoid
Do not treat empirically with antibiotics, corticosteroids, or anti-reflux medications without laryngoscopy. 4, 5 The American Academy of Otolaryngology-Head and Neck Surgery makes a strong recommendation against this practice, as it delays diagnosis of potentially life-threatening conditions. 4
Do not assume the hoarseness is benign or self-limited. Unlike older children and adults where viral laryngitis is common, persistent hoarseness in infants has a much higher likelihood of serious underlying pathology. 1, 2
Do not order imaging before laryngoscopy. Laryngoscopy must come first to guide appropriate imaging studies. 5, 6
Recognize that younger infants have higher rates of vocal cord paralysis (50% in newborns vs. 17% in infants approaching 12 months), making urgent evaluation even more critical in the neonatal period. 2