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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 186-190

Laryngeal manifestation due to smoking among the pediatric age group – Our experiences at an Indian teaching hospital


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Community Medicine, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
3 Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India

Date of Submission08-Jun-2019
Date of Decision03-Sep-2019
Date of Acceptance06-Sep-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_111_19

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  Abstract 


Background and Aim: Smoking among the pediatric age group is a public health concern. It has direct link to laryngeal manifestations. Due to increased exposure to smoking, it is affecting the children directly or indirectly through involving upper airway, particularly the larynx. In this study, we explored the effect of cigarette smoking in laryngeal manifestations among the pediatric age group. Materials and Methods: It is a retrospective study conducted at a tertiary care teaching hospital of eastern India between December 2017 and June 2019. There were 112 pediatric patients between the age of 5 and 16 years with complaints of hoarseness of voice. Out of 112, 32 (28.57%) had history of exposure to cigarette smoking. All the children of this study underwent a careful and detailed general and physical examinations and local examinations such as the ear, nose, and throat. All the children were also subjected to videolaryngoscopy for the assessment of the larynx. Results: The majority of the children with smoking habit were male (59.37%). The most common diagnosis among children with smoking habit was laryngopharyngeal reflux (LPR) (40.62%) followed by chronic laryngitis (25%), vocal fold keratosis (18.75%), Reinke's edema (12.50%), and malignancy (3.12%). All these laryngeal lesions were treated appropriately. LPR and chronic laryngitis were treated with conservative medications and speech therapy. Vocal fold keratosis and Reinke's edema were treated with microlaryngeal surgery and conservative treatment. Conclusion: Smoking has adverse effect on the larynx in the pediatric age group. It has an impact to alter the structural changes in the vocal folds. Speech therapy, vocal hygiene, and absolute cessation of the smoking are ideal treatment for pediatric dysphonia due to the effect of smoking.

Keywords: Hoarseness of voice, laryngeal manifestation, pediatric age group, smoking


How to cite this article:
Swain SK, Behera IC, Mohanty JN. Laryngeal manifestation due to smoking among the pediatric age group – Our experiences at an Indian teaching hospital. Arch Med Health Sci 2019;7:186-90

How to cite this URL:
Swain SK, Behera IC, Mohanty JN. Laryngeal manifestation due to smoking among the pediatric age group – Our experiences at an Indian teaching hospital. Arch Med Health Sci [serial online] 2019 [cited 2020 Jan 28];7:186-90. Available from: http://www.amhsjournal.org/text.asp?2019/7/2/186/273050




  Introduction Top


Tobacco has been used by human beings for more than 2000 years, but before the discovery of America, it was used only by the Indians during festive occasions.[1] There were no harmful effects known to human beings before the 20th century.[1] Now using of smoking became widespread and is often associated with different health problems. Cigarette smoking is strongly linked to the serious diseases of the human being. Smoking among the pediatric age group is a major health threat. Several studies have shown its harmful effects on health. Children are exposed to toxic effects; nicotine is a major harmful agent present in smoking. The toxicity of smoking is directly related to the number of cigarette smoked and inversely related to the age at which the habit was made.[2] Cigarette smoke contains around 7357 types of chemicals, including nitrosamines and radioactive compounds and among them arsenic, benzopyrene, and cadmium.[3] Chronic exposure of the larynx to the cigarette smoke can cause several laryngeal pathologies. Most laryngeal disorders cause hoarseness of voice. Hoarseness of voice is defined as rough, harsh, or breathy quality of voice.[4] It affects the quality of life by affecting emotional, social life due to voice-related dysfunction.[5] Hoarseness of voice is common among certain groups such as teachers, singers, and voice professionals. Due to increased exposure to smoking, it is affecting the children directly or indirectly through involving upper airway particularly the larynx. The aim of this study is to evaluate the effect of cigarette smoking in laryngeal manifestations among the pediatric age group.


  Materials and Methods Top


It is a retrospective study conducted at a tertiary care teaching hospital between December 2017 and June 2019. One hundred and twelve children attended the outpatient department of otorhinolaryngology for hoarseness of voice during the study period. This study included 32 children those had a history of smoking habit either active or passive (second-hand) smoking with laryngeal manifestations. This study was approved by the Institutional Ethics Committee. The age range of the children participating in this study group was 5–16 years. Detail history of voice changes and throat problems were assessed. All the pediatric patients presenting with hoarseness of voice along with habit of smoking are either active or passive in nature. All pediatric patients were examined by fiberoptic videolaryngoscopy to find out laryngeal and pharyngeal pathology. The history of smoking habit was extracted from children and their parents. Pediatric patients who are uncooperative or not willing for examinations and excessive gag reflex or history of any laryngeal trauma, previous laryngeal surgery, history of voice abuse, and history of radiotherapy to head-and-neck region were excluded from this study. Children with dyspnea, acute hoarseness during upper respiratory tract infections (<3 weeks), and genetic syndrome with craniofacial abnormalities were also excluded from this study. The major symptoms of the children participated in this study was hoarseness of voice. The questionnaires made for this study were answered by the parents of the children such as age of the child, gender, vocal symptoms, and history of exposure to cigarette smoking. All the children of this study underwent a careful and detail general and physical examinations and local examinations such as the ear, nose, and throat.


  Results Top


One hundred and twelve attended the outpatient department of otorhinolaryngology with the complaints of hoarseness of voice. Out of the 112 children, 32 had habit of cigarette smoking exposure. Out of 32 children with smoking habits, 19 were male and 13 female. Youngest pediatric patient was age of 5 years, whereas the oldest was 16 years. Out of 32 children, 21 the children were school going and 11 were nonschool going [Table 1]. Out of 32 children, 17 were active smokers and 15 were passive smokers. There were an average of 8 cigarettes smoked by each active smoker per day for average of 6 years. However, passive smokers were exposed to average of 4 h to cigarette smoke per day for average of 3 years. Majority of passive smokers are in the age group are in 5–10 years, whereas majority of active smokers are in the age group of 11–16 years [Table 2]. The common complaints recorded from the children were hoarseness of voice. Other than hoarseness of voice, dry irritating cough was in 11 cases and foreign-body sensations in throat in 23 cases were also presented by the children [Table 3]. The duration symptoms were more than 3 months. Laryngopharyngeal reflux (LPR) [Figure 1] was found in 13 patients (40.62%), 8 children presented congested vocal folds [Figure 2] i.e., chronic laryngitis (25%), 6 patients showed vocal fold keratosis [Figure 3] (18.75%), 4 patients showed Reinke's edema [Figure 4] (12.50%), and 1 case presented with laryngeal growth [Figure 5] (3.12%) [Table 4]. Out of six cases of vocal fold keratosis, four patients underwent microlaryngeal surgery with biopsy which revealed nondysplastic and nonmalignant cells. Rest two cases of early vocal fold keratosis were under observation with conservative treatments such as speech therapy along with stem inhalation, antireflux measures, and cessation of smoking. Out of the four cases of Reinke's edema, three cases underwent microlaryngeal surgery and stripping of the vocal folds, whereas rest one case with early lesions treated with conservative medications, speech therapy, and cessation of smoking. There was one case of laryngeal growth that underwent direct laryngoscopy and biopsy under general anesthesia and histopathology report confirmed squamous cell carcinoma. This case of glottic carcinoma (T1N0M0) sent for radiotherapy and revealed normal at follow-up of 3 months of radiotherapy. Speech therapy was done in all cases by speech and language therapist along with vocal hygiene care.
Table 1: Detailed patient profile of children with smoking habit

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Table 2: Age group and smoking habit

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Table 3: Symptomatology of the children with smoking habit

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Figure 1:Endoscopic picture showing laryngopharyngeal reflux

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Figure 2: Endoscopic picture showing chronic laryngitis

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Figure 3: Endoscopic picture showing vocal fold keratosis

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Figure 4: Endoscopic picture showing Reinke's edema

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Figure 5: Endoscopic picture showing glottic growth

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Table 4: Pathological changes in the larynx of the children with smoking habits

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  Discussion Top


Hoarseness of voice or dysphonia is a common clinical symptom among the pediatric age group. Hoarseness of voice is defined as altered quality of voice perceived as harsh, rough, or breathy sound due to abnormal movement of vocal fold.[6] It is not a diagnosis but a symptom, so need a careful assessment to find out the underlying cause.[7] The etiology includes laryngitis, vocal abuse, smoking, laryngeal trauma, and thyroid surgery.[8] There are also a cluster of risk factors associated with laryngeal diseases and dysphonia. The risk factors include age, sex, occupation, smoking, and alcohol. Out of these risk factors, smoking is an important factor which directly damages the laryngeal mucosa and cause hoarseness of voice. In this study, focusing was given on cigarette smoking as etiology on pediatric dysphonia. The prevalence of dysphonia in pediatric age group between 8 and 14 years varies from 3.9% to 23.4%.[9] The children of the parents those smoke in comparison to the children of nonsmokers parents have more chance of respiratory infections, laryngeal injury, and increased respiratory or laryngeal symptoms.[10] Laryngeal manifestations such as dysphonia have a negative impact on social communication, educational development, self-image, general health, and participation in social development. Parents of the children and peers usually judge the dysphonic children more negatively than children with normal voice.[11] The detrimental effects of cigarette smoking either passive or active on human health are widely known. There are certain changes occur in the larynx following chronic smoking. Chronic inflammatory changes occur in the larynx due to smoking, and this is called group of symptoms, called smoker's larynx. Different sources for cigarette smoking are classified as first-, second-, and third-hand smokers. Primary users of cigarette producing smoke are called as first-hand smokers. Second-hand smokers are passive smokers, those are exposed to burning tobacco products. Third-hand smokers are due to exposure of the areas or surfaces contaminated from the second-hand smokers (National Cancer Institute; 2017). Smoking images in movie, commercial advertising of cigarette smoking, and celebrities smoking attract children and adolescents for cigarette smoking. In certain movies, smoking is appealing toward toughness, sexiness, and rebelliousness, so provide temptation to smoke among adolescent and young children.[12] Smoking cigarettes per day and duration of smoking will determine the extent of damage to the larynx.[13] When larynx is exposed to cigarette smoke, epithelial lining of the vocal folds are altered, leading to Reinke's edema and keratosis of the vocal folds. Pediatric vocal fold epithelium and lamina propria were thinner than adult and could be vulnerable to mechanical injury.[14]

The differential diagnosis of hoarseness of voice in pediatric patients is broad. A careful and thorough evaluation is needed for exact diagnosis of the etiology for pediatric dysphonia. Majority of children in this study are diagnosed with LPR. LPR is an inflammatory disease due to backflow of the gastric acid into the larynx and pharynx, where it contacts to the tissues of the upper aerodigestive tract.[15] The physiological barriers for preventing LPR are lower esophageal sphincter, esophageal clearance influenced by esophageal peristalsis, gravity, saliva, and upper esophageal sphincter. When these physiological barriers fail, stomach content (acid) come in touch with the laryngopharyngeal tissues, leading to damage of epithelium, ciliary dysfunction, altered sensitivity, and inflammation. The quality of voice is affected in 6%–23% of school-going children.[16] LPR is a well-established etiology for hoarseness of voice in children.[17] The most common clinical symptoms in LPR are persistent cough, throat clearing, globus pharyngeus and hoarseness of voice.[18] Reinke's edema is characterized by swellings of the vocal folds and often bilateral and more pronounced in one fold. There are abnormal tissue changes in the subepithelial connective tissue of the vocal folds. It is a chronic and benign disease involving vocal folds with collection of fluid within the superficial layer of lamina propria, so restricting the vibration of the vocal folds leading to dysphonia.[19] Smoking, voice abuse, and LPR account for the causes of Reinke's edema.[20] Laryngeal keratosis is a rare clinical entity seen in vocal fold and characterized by irregular areas of thickening and cornification of mucosal lining of the larynx. It is called as leukoplakia of the larynx or pachydermia laryngitis.

Indirect laryngoscopy is a basic clinical examination of the larynx in the outpatient department of otorhinolaryngology but is not much helpful in pediatric patients. Videolaryngoscopy (VLS) is a better technique for examination of the larynx of the children which also provide clarity of the laryngeal picture and helpful for data preservation facility. It is also helpful for comparing before and after treatment of the laryngeal lesions. VLS usually allows preferential examination of specific area of the larynx with affecting the patient.[21] VLS is often recommended for routine screening of laryngeal lesions in the pediatric age group. Flexible nasopharyngolaryngoscopy is often required to assess the pediatric dysphonia and identify the morphodynamic alterations of the vocal folds. Videolaryngoscopy examinations of the pediatric patients provide larger magnification, better angle of visualization, better illumination, and resolution of the larynx in pediatric patients. Strobsocopy is usually useful in older children. Virtual endoscopy is nowadays advised and often used as replacement for classical laryngeal endoscopy during follow-up of the patients.

The effective treatment of the laryngeal pathology requires proper diagnosis and identification of the aggravating factors. The treatment of the pediatric dysphonia requires individual basis. The treatment options include proper counseling, cessation of smoking, speech therapy, medical treatment, and surgical interventions. There is an increased attention directed toward cessation of passive smoking in the pediatric age group. If cessation or avoidance of cigarette smoking is impossible, making less concentration of particulate and vapor phases of smoke from cigarette is an effective way for decreasing the smoking's effect. This can happen by smoking in well-ventilated places with increased air exchange rates or using filters or air purifiers. Once the smoke reaches the laryngeal mucosa, affect it with irreversible manner, so avoidance is the best possible prevention. If the alteration of the laryngeal mucosa by smoking is accentuated by inflammatory response from viral infections or allergic exposure, so reduction of the smoking will benefit the larynx of the patients. The use of steroid inhalations helps in rapid tissue response and encourage the rapid recovery. Appropriate treatments of infections or allergy are also hopefully benefiting the patients by protecting the larynx. Unusual lesion of the larynx like keratosis is still eluding us in our day-to-day clinical practice. Pediatric otolaryngologists or clinician should be vigilant to diagnose such clinical entity and treat it effectively, as it often mimics to malignant lesions. Sometimes, it is large often to obstruct the laryngeal airway which may require emergency tracheostomy. Proper history taking, adequate anatomical knowledge of the larynx, thorough clinical examination, and endoscopic examination of the larynx help in adequate management of such lesions with best outcome. Out of six cases of laryngeal keratosis in this study, four patients underwent microlaryngeal surgery with biopsy which revealed nondysplastic and nonmalignant cells. Rest two cases of laryngeal keratosis with minimal lesions were under observation with conservative treatments such as speech therapy along with stem inhalation, antireflux measures, and cessation of smoking. Reinke's edema is a benign lesion of the vocal folds manifesting as diffuse polypoidal degeneration due to edema and vascular congestion of the Reinke's space. In Reinke's edema, the treatment includes avoidance of irritants such as smoking, microsurgical removal of strip of vocal folds, and absolute voice rest for period of 1 week. Although mainstay of treatment of Reinke's edema is surgery, other modalities of treatment are intracordal steroid injection and avoidance of smoking are important management.[22] Different surgical options in Reinke's edema include stripping of the vocal folds, aspiration of fluid from Reinke's space/subepithelial space, subepithelial laser coagulation, microflap-based laryngeal surgery, microdebrider-assisted removal of subepithelial fluid, and microsuture techniques.[23] In our study, out of four cases, three cases underwent microlaryngeal surgery with stripping of the vocal folds, whereas in one case with early lesion of Reinke's edema treated with conservative medication, speech therapy, and cessation of smoking. Cigarette smoking is a risk factor for dysphonia among children by causing different laryngeal pathologies. Based on the result of this study, early cessation of smoking is needed for prevention of the laryngeal pathology in the pediatric age group.


  Conclusion Top


Dysphonia among children is not an uncommon clinical entity. Dysphonia among children has the potential risk for behavioral or emotional abnormalities. It compromises the personality of the child. Smoking has a significant impact on larynx and leading to dysphonia. Smoking among the pediatric age group is a worrisome problem in the society. Cigarette smoking is an aggravating factor for causing laryngeal pathologies such as LPR, chronic laryngitis, laryngeal keratosis, Reinke's edema, and laryngeal malignancy. This study shows that smoking has a significant effect on larynx of the pediatric patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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