Muffled Voice

Dear Lisa,

My 5 year old son's (6 next month) voice sounds like he has a large amount of spit in his mouth, I don't see anything in there, it sounds like Kermit the frog, my husband said it sounds like he has marbles in his throat. He says he feels ok, he's eating/drinking, he doesn't feel hot, no c/o sore throat, no coughing, no runny nose, he does snore loudly at night. What could this be?

“Mommy of 2”

Dear “Mommy of 2”,

Children usually develop a marbled, muffled voice when they have mucus in the upper airway or when they don’t swallow their saliva properly. Mucus can build up in the upper airway due to a multitude of reasons. A child can develop extra mucus during a cold, due to allergies or due to improper drainage because of a blockage in the upper airway.

If this is a new finding in your son, his symptoms may be due to an Upper Respiratory Infection such as a cold or virus. Since he does not have any pain, loss of appetite or fever with his symptoms, I would be inclined to think that his symptoms are due to another cause. Persistent or long standing symptoms could be due to, Allergies, Oral-motor dysfunction or a blockage in his airway caused by enlarged tonsils and/or adenoids.

Tonsillar or Adenoid Hypertrophy or enlarged tonsils or adenoids are two of the of the more common reasons for blockage in a child’s upper airway and ineffective drainage of secretions. During childhood, tonsils and adenoids become enlarged in response to infections in the upper respiratory tract.(1) In most children this enlargement is temporary, well tolerated and has no consequences.

In some cases, the enlargement of the tonsils and adenoids can become persistent or obstruct the airway. As a result children can develop symptoms of upper airway obstruction or Obstructive Sleep Apnea (OSA). Signs of upper airway obstruction include mouth breathing, difficulty swallowing, and failure to thrive. (2) Signs of Obstructive Sleep Apnea include loud snoring, pauses in breathing during sleep, restless sleep, interrupted sleep, excessive daytime sleepiness, Attention deficit disorder, impaired concentration, impaired attention, morning headaches, bedwetting, dry mouth, depression, irritability, and abnormal sleep positions. (2,3,4)

Obstructive Sleep Apnea causes a child to receive decreased amounts of oxygen while they sleep. (3) It is a major health concern because most cases go undetected and because the long term effects of untreated OSA can be quite serious.(3) These long term consequences include glucose intolerance, elevated cholesterol levels, hypertension and cardiovascular disease along with its complications. (5,6). Therefore it is prudent to take symptoms of Obstructive Sleep Apnea seriously and seek the expertise of an Otolarngologist if symptoms occur.

Another potential cause for a muffled voice and a child who sounds like he has marbles in his throat is Allergies or Hay Fever. Allergies or Hay fever usually present with sneezing, watery itchy eyes, runny nose and nasal congestion. Other signs of allergies include nasal blockage, post-nasal drip, nasal itching, and nose rubbing (also known as the Allergic Salute), an allergic crease on the nose, itchy throat, throat clearing, mouth breathing, snoring, and a nasal voice.(7) Typical indoor allergies that occur during the winter months include; dust mite allergies, mold allergies and allergies to mouse urine, cockroaches and domestic pets. (8)

Children are at risk for developing allergies if their parents suffer from Allergies or Hay Fever. It is expected that 47% of children who have two parents with allergies will also develop Allergies.(9) If your son is exhibiting symptoms of Allergies and there is a family history of Allergies it would be a good idea to bring this to your Doctor’s attention. In some cases, an Allergist may need to be consulted for an evaluation and allergy testing in order to confirm the diagnosis.

If your son’s symptoms are accompanied by drooling, difficulty chewing, garbled speech, a delay in his speech development or your inability to understand his words, Oral-motor dysfunction may need to be considered. Oral-motor dysfunction occurs when a child experiences decreased muscle tone or difficulty with coordination of the muscles in his mouth. Children with Oral-motor dysfunction tend to have difficulty handling their secretions, problems chewing and swallowing certain types of foods and a delay in speech development.

An evaluation by a Speech therapist can determine if a child is suffering from Oral-motor dysfunction, a problem with his swallowing mechanism or a Speech delay. If a problem is detected the Speech Therapist can provide therapy, teach your child exercises and recommend techniques that can be used at home to help rectify the situation.

A muffled voice accompanied by drooling, a sitting forward position, stridor (high pitched inspiratory sound), difficulty swallowing or fever may represent a different condition such as Foreign body aspiration, Epiglottitis or Tracheitis. (2) These conditions are considered to be Medical Emergencies that need to be evaluated by a Physician without delay.

I hope your son’s symptoms resolve and he is back to himself soon.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Tonsillectomy

Snoring

Hay Fever Symptoms

Treatment for Hay Fever

Speech Delay

Infant Drooling

Toddler Swallowed Paperclips

References:
(1) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1211-1213.
(2) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990: 805,500-501.
(3)Butler D. An underdiagnosed cause of daytime fatigue. The Clinical Advisor. 2006. Sept:48-52.
(4)Picchietti D, England S, Walters A, Willis K, Verrico T. Periodic Limb Movement Disorder and Restless Legs Syndrome in Children with Attention-deficit Hyperactivity Disorder. Journal of Child Neurology. 1998. 13(12)588-594.
(5)Yaggi HK, Concato J, Kernan WN. Obstructive Sleep Apnea as a risk factor for stroke and death. N Engl J Med. 2005. 353:2034-2041.
(6)Mehra R, Benjamin EJ, Shahar E. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep heart Health Study. Am J Respir Crit Care Med. 2006.173:910-916.
(7)Lai L, Casale TB, Stokes J. Pediatric allergic rhinitis: Treatment. Immunol Allergy Clin N Am. 2005. 25:283-299.
(8)Phipatanakul W. Environmental Indoor Allergens. Pediatric Annals. 2003. 32(1):40-48.
(9)Berger W. Overview of allergic rhinitis. Ann Allergy Asthma Immonol. 203. 90:7-11.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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