This article describes the assessment and behavioral treatment for paradoxical vocal fold motion disorder (PVFM), chronic cough, and laryngospasm. Behavioral treatment for these disorders is coordinated by the speech–language pathologist. Assessment of PVFM involves a detailed behavioral analysis of the triggers for the conditions and incorporation of the medical findings as they relate to the symptoms. Treatments developed originally by the group at the National Jewish Hospital in Denver, Colorado, and then expanded by others have been shown to reduce or eliminate the symptoms and improve overall quality of life in patients who have these diagnoses.
Gastroesophageal reflux disease (GERD), paradoxical vocal fold motion (PVFM), chronic cough (CC), and laryngospasm are significant medical problems that share many common signs and symptoms. However, they are treated differently by numerous disciplines, resulting in a plethora of outcomes, including acceptable responses, failed treatments, and partial responses. The varied characteristics associated with this triad of conditions are often severe, and usually clinicians focus on the most severe occurrences when patients are seen initially. Complaints of episodic choking, shortness of breath, and cough command attention from pulmonologists, allergists, and gastroenterologists. However, a growing body of evidence suggests that otolaryngologists and speech–language pathologists should provide the definitive and long-term management of patients who have these disorders.
Regarding PVFM, the overwhelming impression derived from the literature from the past 25 years is that the various disease titles and descriptions confound the understanding of its pathophysiology and neuropathology. Is PVFM the same as CC that is refractory to standard medications? Is PVFM a result of a laryngospasm? Is laryngospasm prompted by severe episodes of upper respiratory irritation and CC? These circumferential questions show that no clear understanding exists of the symptoms associated with each of these conditions or their underlying mechanisms. Table 1 presents further evidence that the definitions of these conditions somewhat overlap, creating difficulty in accurately defining them. A review of several journals produced the list of terms that contain descriptions that resemble each other and implicate CC, laryngospasm, or PVFM.
| Paradoxical Vocal Fold Motion | Chronic Cough | Laryngospasm | |
|---|---|---|---|
| Vocal cord dysfunction | X | X | |
| Munchausen’s stridor | X | ||
| Functional airway obstruction | X | X | X |
| Paradoxical vocal cord dysfunction | X | X | X |
| Episodic paroxysmal laryngospasm | X | X | |
| Adult onset asthma | X | X | X |
| Factitious asthma | X | ||
| Paradoxical vocal fold movement | X | X | X |
| Breathing abnormalities | X | X | X |
| Psychogenic stridor | X | X | X |
| Irritable larynx syndrome | X | X | X |
| Laryngeal dyskinesia | X | X | |
| Trigeminal neuralgia | X | X | X |
Although evidence may suggest that these three conditions have similar underlying mechanisms, they are often treated according to a standard set used by the specialist who initially sees the patient. This variation in treatment standards may result in misdiagnosis or failed or partial treatments. In the most unfortunate cases, it may result in the patient taking needless medications.
The occurrence of PVFM, CC, or laryngospasm clearly centers on symptoms that involve some degree of vocal fold adduction, either for an instant or up to several seconds. Highly variable conditions trigger this behavior, not only among patients but often within the same patient. This article briefly reviews the three conditions as they relate to a multidisciplinary team, including otolaryngologists and speech–language pathologists.
Laryngospasm
Laryngospasm is a serious condition defined as a sudden-onset, rapid, and forceful contraction of the laryngeal sphincter, resulting in airway obstruction or complete glottic closure and apnea for up to 20 seconds. Occurring in response to noxious stimuli, laryngospasm may represent an abnormal excitation or loss of inhibition of the laryngeal closure reflex. Known concomitant conditions that can lead to a laryngospasm include PVFM, vocal fold paralysis, irritable larynx syndrome, GERD, and trigeminal neuralgia.
The most commonly described signs and symptoms associated with laryngospasm in children and adults include (not necessarily in this order of frequency) choking, breathing disruptions, dysphagia, aspiration, dyspnea, episodes of complete airway obstruction, stridor (a continuous sound during inspiration), voice disorders (aphonia and dysphonia), cough, throat clearing, globus, and pain in the jaw area (presumed to represent a traumatic glossopharyngeal neuralgia). Many of these same signs are associated with PVFM and CC.
In a group of 10 individuals who had laryngospasm, Gallivan and colleagues found evidence of various symptoms, including stridor, choking, allergies to foods, and cough. The vocal fold movement in these individuals was described as inspiratory adduction of the anterior vocal fold and a diamond-shaped posterior glottic gap.
Paradoxical vocal fold motion
PVFM is a laryngeal disorder that affects respiratory function through obstructing the airway in the closing or partial closing of the vocal folds during inspiration. Furthermore, because of the closing motion of the vocal folds, PVFM can also impact voice production. The paradoxical motion has been shown to occur primarily during inhalation but may also occur during both inhalation and exhalation. The multiplicity of patients’ complaints often leads to incorrect diagnoses and more importantly a series of failed treatments.
PVFM, sometimes referred to as vocal cord dysfunction [VCD], has been associated with CC and laryngospasm. Vertigan and colleagues outlined the recent history of the relationship between CC and PVFM. Studies by several other investigators indicate that a large number of individuals who had abnormal vocal fold motion complained of cough that continued for long periods. In a study using flexible endoscopy and stroboscopy, Treole and colleagues described the paradoxical motion in patients complaining of cough, choking and shortness of breath while they were sitting comfortably and not talking or exercising.
Paradoxical vocal fold motion
PVFM is a laryngeal disorder that affects respiratory function through obstructing the airway in the closing or partial closing of the vocal folds during inspiration. Furthermore, because of the closing motion of the vocal folds, PVFM can also impact voice production. The paradoxical motion has been shown to occur primarily during inhalation but may also occur during both inhalation and exhalation. The multiplicity of patients’ complaints often leads to incorrect diagnoses and more importantly a series of failed treatments.
PVFM, sometimes referred to as vocal cord dysfunction [VCD], has been associated with CC and laryngospasm. Vertigan and colleagues outlined the recent history of the relationship between CC and PVFM. Studies by several other investigators indicate that a large number of individuals who had abnormal vocal fold motion complained of cough that continued for long periods. In a study using flexible endoscopy and stroboscopy, Treole and colleagues described the paradoxical motion in patients complaining of cough, choking and shortness of breath while they were sitting comfortably and not talking or exercising.
Chronic cough
CC has been defined as cough that persists for longer than 8 weeks despite medical management. Although many individuals who require treatment for a cough respond to medical management, a percentage of individuals continue to cough despite medical intervention. Unlike cough that occurs with a flu or upper respiratory infection, CC is a dry-sounding cough occurring randomly throughout the day. It may be triggered by various events, such as exposure to cold air, smoke, perfume, or soap powder, or activity such as walking, talking, or laughing. In one study, Vertigan and colleagues observed that approximately 50% of individuals who had CC were habitual mouth breathers, suggesting a drying effect on the laryngeal tissues and creating an irritating trigger.
GERD and laryngopharyngeal disease (LPR) are believed to be the causative factors in more than one half of adults who have CC. However, cough and GERD/LPR are common conditions that affect adults and children, and they may have a high rate of coexistence, if only by chance. GERD/LPR may be controlled with diet management, proton pump inhibitors, prokinetic agents, and antianxiety medications. However, pharmacologic agents alone do not stem the CC even when the GERD/LPR conditions are improved. Moreover, CC is often accompanied by other conditions, such as hoarseness and PVFM. Thus, a need exists for a complete evaluation of the onset factors, especially when common treatment methods do not reduce the CC.
Patients who have CC are usually seen by a pulmonologist; however, when no pulmonary component is found, patients often must seek help from other specialists and try other medical management without success. Murry and colleagues reported on 5 patients who had a history of CC and were ultimately diagnosed with PVFM who had an average duration of symptoms before diagnosis of 66 months (5.5 years) with a range of 5 to 158 months (>13 years).
These findings suggest that CC, PVFM, and laryngospasm may be overlapping conditions, which leads to the following questions: Is PVFM a response to cough? Is the laryngospasm a severe episode of PVFM? Is cough a response to the adductory vocal fold motion seen in PVFM? These questions suggest a focused laryngeal component to CC, laryngospasm, and PVFM, once pulmonary issues are ruled out. The terminology in Table 1 may reflect the overlapping relationship among CC, PVFM, and laryngospasm. Clearly, as Andrianopoulos and colleagues pointed out in the review of these conditions, a thorough diagnosis is critical to successful medical and behavioral management of these conditions.
Evaluation by the Speech–Language Pathologist
In the past, CC, PVFM, and laryngospasm were considered separate entities. More recently, however, the conditions have been shown to have many similarities and thus may be considered overlapping or associated. Because of close association among CC, PVFM, and laryngospasm, the overall management typically involves several specialists because the patient’s complaints encompass breathing difficulties, swallowing abnormalities, dysphonia, and an overall degradation in quality of life. The evaluation of PVFM, CC, and laryngospasm consists of medical examinations and behavioral assessments. Other articles in this issue outline the medical evaluations and tests, including flexible endoscopy and a thorough head and neck examination by an otolaryngologist, pulmonary workup, and chest radiograph by a pulmonologist, and evaluation by a gastroenterologist, which may include esophagoscopy.
Equally important in the management of patients who have symptoms of PVFM, CC, and laryngospasm is the role of the speech–language pathologist. Christopher and colleagues were among the first groups to identify the importance of the speech–language pathologist in the care of patients who have PVFM. Andrianopoulos and colleagues studied a group of 27 patients and identified 51.8% who had episodic acute aphonia, 18.5% hoarseness, and 44.4 % dysphagia. However, these percentages vary widely depending on the presence of other conditions or diseases. For example, Cukier-Blaj and Murry reported on 70 patients who had laryngospasm and laryngopharyngeal reflux and found the related signs and symptoms to include several patients who had both dysphonia and dysphagia. Their results are summarized in Table 2 .
| Symptoms | % |
|---|---|
| Throat clearing | 80.0 |
| Throat mucus | 74.3 |
| Hoarseness | 68.6 |
| Annoying cough | 62.9 |
| Something sticking in the throat | 54.3 |
| Breathing difficulties | 48.6 |
| Coughing after lying down | 42.9 |
| Heartburn/chest pain | 42.9 |
| Difficulty swallowing | 28.6 |
The speech–language pathologist provides critical assessment of the conditions surrounding these signs and symptoms and performs tests to determine the exact nature of the complaint. The components of the evaluation include patient self-assessment, perceptual assessment of the voice, instrumental assessment of voice and swallowing (if symptoms warrant), and trial therapy. The speech–language pathologist should have access to the laryngoscopic examination and pulmonary data. The flexible endoscopic examination should be noted for evidence of paradoxical motion during quiet breathing. The spirometry tests should be noted for the flattened inspiratory curve often seen in patients who have PVFM.
Several tools may be used to obtain the patient’s perception of the problem. The Voice Handicap Index or Voice Handicap Index-10 (VHI-10) provides valid and reliable assessments of patients’ perception of voice severity. The Dyspnea Index offers additional information regarding patients’ self-assessment of breathing difficulty.
At the initial evaluation, the SLP should focus on issues relating to the onset of the primary problem (eg, cough, shortness of breath, swallowing difficulty). Specifically, when and how did the primary problem begin? Often patients may not recall and they must be prompted regarding events, such as sickness, travel, new medications, and lifestyle changes. The speech–language pathologist should probe each issue to determine how the event may be related to the primary problem. Focusing on the primary problem is important because most patients have had the problem for a long time and tend to mention issues that may not be part of the primary problem. Once the primary problem onset has been established, the evaluation proceeds.
Identifying the triggers that cause the primary symptom (cough or shortness of breath) is important. Having a few different soap powders or perfumes in the office may be helpful. Other triggers that may be more subtle include speaking, swallowing rapidly, walking, running, or simply going from indoors to outdoors or vice versa.
Laryngeal palpation of the suprahyoid and infrahyoid muscle groups may help to identify excessive neck tension. Careful palpation during inhalation and exhalation may identify intrinsic or extrinsic laryngeal muscle tightness. Palpation during the initiation of phonation may identify an elevated laryngeal position. Observation of the shoulders and chest during quiet breathing and during speech may also reveal abnormal breathing patterns. Inspiration accompanied with shoulder lifting and chest tightening often brings on cough or shortness of breath associated with speaking.
Trial therapy should always be a part of the initial evaluation by the speech–language pathologist. Rhythmic breathing exercises as outlined later may produce a more relaxed breathing posture and cue the patient to understanding the nature of the problem. Alternatively, if the voice is dysphonic, voice exercises to modify voice production are appropriate during the trial therapy period. Previous studies have shown that approximately 35% of patients who have CC, PVFM, or laryngospasm complain of dysphonia, even if it is not the primary complaint.
Instrumental assessment depends on the symptoms. If the patient’s voice is dysphonic, acoustic analysis of the voice is helpful to establish baseline information of voice quality. Other instrumental assessments may include flexible endoscopy (if not already performed by the otolaryngologist), aerodynamic assessment during speech, and voice and spirometry, including careful study of the inspiratory phase of the flow volume loop.
Spirometry provides significant objective evidence of normal pulmonary function. Measures of forced vital capacity and other expiratory measures provide an indication of the health or disease of the lungs. Patients who are coughing, feel short of breath, or have chest tightness are seen routinely by a pulmonologist, and spirometric measures are usually obtained. A methacholine challenge test is also performed to help assess for the possibility of cough-variant asthma that usually presents with normal baseline spirometry. However, in many cases, spirometry only includes the expiratory measures, such as forced expiratory volume in one second or maximum voluntary ventilation and the maximum expiratory flow–volume loop. In particular, the flow–volume relationships diagnose the presence and can assess the effect of large (central) airway obstructions.
Several investigators have shown that patients who have PVFM have abnormal inspiratory loops in their spirometry. Several investigators, such as Altman, Murry and colleagues, and Hartnick, have shown a flattened inspiratory loop in patients who have PVFM compared with a U-shaped inspiratory flow loop seen in normal subjects.
Exercise
Occasionally, it may be helpful to have the patient undergo a short period of exercise to determine if breathing patterns change or speech and voice become degraded after increased activity. Rapid walking, step climbing, and pedaling a stationary bike may elicit the primary or secondary symptom.
Once the evaluation by the speech–language pathologist is complete, the data should be reviewed with the otolaryngologist and others participating in the patient’s care. A coordinated approach to treatment may include pharmacotherapy, inhalation therapy, or further referral based on the findings.
Speech–language pathologist treatment
Table 3 lists the possible treatments for CC, laryngospasm, and PVFM. This article focuses on behavioral treatments usually provided by a speech–language pathologist. Other articles in this issue address medical treatments.
