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Role of the Speech

Pathologist in the

Management of Irritable

Larynx SyndromeJill Fitzpatrick, MA, CCC-SLP

Arkansas Otolaryngology Center

jfitzpatrick@aoc.cc

ARKSHA October 13, 2016

Irritable Larynx Syndrome by any other

nameTerms used include:

Vocal Cord Dysfunction Paradoxical Vocal Cord Movement

Laryngospasm Globus

Anxiety Disorder Panic Disorder

Non-organic Wheezing Munchausen's Stridor

Episodic Laryngeal Dyskinesia Pseudoasthma

Spasmodic Croup Emotional Laryngeal Wheezing

Hypersensitivity Syndrome Hyperkinetic Laryngeal Dysfunction

(Ibrahim 2007; Murry 2009)

Symptoms of ILS

Symptoms may include:

-Chronic Cough -Dysphagia

-Laryngospasm -Hoarseness

-Globus Pharyngeus

-Chronic Persistent Throat Clearing Behavior

-Paradoxical Vocal Cord Movement

Evaluation

ILS is a multi factorial disorder and diagnosis requires assessment of each

patient’s described symptoms. Listed are common assessment

tools/strategies utilized:

-Laryngeal Videostroboscopy

-pH Probe

-Chest x-ray

-Videofluoroscopic Evaluation of Swallowing

-Pulmonary Function Studies

-Allergy Testing

-Voice Evaluation to include use of VHI, CSI, RIS

**Critical to have ENT evaluation to visualize the larynx before initiating

treatment

AOC ILS Evaluation Protocol

Patient is scheduled in the AOC Voice, Swallowing and Airway Clinic

On appointment day the patient will be asked to fill out the following forms:

Voice Handicap Index -VHI-10 Reflux Index Scale-RIS

Koughman Cough Index Cough Severity Index- CSI

Voice History Sheet Maximum Phonation Time

A detailed medical history is taken by physician and speech pathologist

The physician performs a thorough exam of the ear, nose and throat to

include indirect exam with mirror

A laryngeal videostroboscopy is performed and reviewed with patient

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AOC ILS Evaluation Protocol con’t

A voice Evaluation is completed and trial of therapy initiated if

appropriate and time allows

Patient may undergo hearing evaluation and/or CT if medically

warranted

A medical treatment plan is created with the patient that may

include:

Swallow study GI referral Pulmonary referral

Allergy referral Speech therapy Physical therapy

Pharmacology pH probe

The patient is scheduled for a follow up-3 months typically

Voice Handicap Index-100=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=

Always

1. My voice makes it difficult for people to hear me. 0 1 2 3 4

2. People have difficulty understanding me in a noisy room. 0 1 2 3 4

3. My voice difficulties restrict personal and social life. 0 1 2 3 4

4. I feel left out of conversations because of my voice. 0 1 2 3 4

5. My voice problem causes me to lose income. 0 1 2 3 4

6. I feel as though I have to strain to produce voice. 0 1 2 3 4

7. The clarity of my voice is unpredictable. 0 1 2 3 4

8. My voice problem upsets me. 0 1 2 3 4

9. My voice makes me feel handicapped. 0 1 2 3 4

10. People ask, “What’s wrong with your voice?” 0 1 2 3 4

Reflux Index ScaleWithin the last MONTH, how did the following problems affect you?

0= no problem 5= severe problem

1. Hoarseness or a problem with your voice. 0 1 2 3 4 5

2. Clearing your throat. 0 1 2 3 4 5

3. Excess throat mucous or postnasal drip. 0 1 2 3 4 5

4. Difficulty swallowing food, liquids, or pills. 0 1 2 3 4 5

5. Coughing after you ate or after lying down. 0 1 2 3 4 5

6. Breathing difficulties or choking episodes. 0 1 2 3 4 5

7. Troublesome or annoying cough. 0 1 2 3 4 5

8. Sensations of something sticking in your throat/lump in your throat? 0 1 2 3 4 5

9. Heartburn, chest pain, indigestion, or stomach acid coming up 0 1 2 3 4 5

Cough Severity Index

0 = NEVER 1= ALMOST NEVER 2= SOMETIMES 3= ALMOST ALWAYS 4= ALWAYS

MY COUGH IS WORSE WHEN I LIE DOWN. 0 1 2 3 4

MY COUGHING PROBLEM CAUSES ME TO RESTRICT MY PERSONAL AND SOCIAL LIFE. 0 1 2 3 4

I TEND TO AVOID PLACES BECAUSE OF MY COUGH PROBLEM. 0 1 2 3 4

I FEEL EMBARRASSED BECAUSE OF MY COUGHING PROBLEM. 0 1 2 3 4

PEOPLE ASK, “WHAT’S WRONG?” BECAUSE I COUGH A LOT. 0 1 2 3 4

I RUN OUT OF AIR WHEN I COUGH. 0 1 2 3 4

MY COUGHING PROBLEM AFFECTS MY VOICE. 0 1 2 3 4

MY COUGHING PROBLEM LIMITS MY PHYSICAL ACTIVITY. 0 1 2 3 4

MY COUGHING PROBLEM UPSETS ME. 0 1 2 3 4

PEOPLE ASK ME IF I AM SICK BECAUSE I COUGH A LOT. 0 1 2 3 4

Koufman Chronic Cough Index

Koufman Chronic Cough Index (KCCI)

Is the main reason you are here CHRONIC COUGH? ___________________; If so, for how many years? ____________

When your cough began, had you had a respiratory infection, cold, the flu, or other illness? ________________________

Have you had a chest x-ray within the last two (2) years? Y N; was it normal? _________________________________

Have you seen a pulmonologist (lung doctor)? Y N; if so, date and name of physician ___________________________

Have you seen a cardiologist (heart doctor)? Y N; if so, date and name of physician _____________________________

Are you on a blood pressure medicine? Y N; if so, which & dose? ____________________________________________

Have you seen an allergist? Y N; if so, date & name of physician & allergies identified___________________________

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Koufman Chronic Cough Index con’t

Do you awaken from a sound sleep coughing Yes No ______________________________

violently? How often? With trouble breathing?

Do you have choking episodes when you cannot Yes No ______________________________

get enough air, gasping for air? If so, how often?

Do you usually cough when you lie down into Yes No ______________________________

the bed, or when you just lie down to rest?

Do you usually cough after meals or eating? Yes No ______________________________

Do you cough when (or after) you bend over? Yes No ______________________________

Do you more-or-less cough all day long? No Yes ______________________________

Does change of temperature make you cough? No Yes ______________________________

Does laughing or chuckling cause you to cough? No Yes ______________________________

Do fumes (perfume, automobile fumes, burned No Yes ______________________________

toast, etc.) cause you to cough?

Does speaking, singing, or talking on the phone No Yes ______________________________

cause you to cough?

R______ ______N Chronic cough form H 2-7-12

(R=Reflux, N=Neurogenic)

pH Probe

Normal

pH

probe

Abnormal

pH probe

Cough Management

Four Components to treatment of cough:

- Education

-Cough Control Techniques

-Vocal Health Training

-Psychoeducational Counselling

(Vertigan 2011)

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Cough Education

Critical component to treatment

Patients require a strong rationale to change their behavior.

Working with the concept that there is nothing in the airways that requires

expectoration despite the sensation is key

Behavioral Management of cough suppression is the goal despite the

triggering sensation

There is capacity for voluntary control over the cough. While the brainstem

has a vital role in cough so does the cerebral cortex. We aim to strengthen

that during treatment.

May not always find a cause for the cough, once the major causes have been

excluded, we focus on symptom control rather than cause.

(Chamberlain 2013; Vertigan 2011)

Cough Control Techniques

The goal is to prevent or interrupt the cough despite the triggering sensation.

Teach patients to identify warning signals, triggering sensations or urge to cough and then substitute a competing response.

Competing responses can include:

cough suppression swallow relaxed throat breathing

pursed lip breathing distraction techniques.

(Vertigan 2007; Vertigan 2012)

Cough Suppression Swallow

At the very FIRST sign of a cough:

Swallow with your hands pushed together

Head down towards your chest

Effortful Swallow (lips together, lift tongue towards roof of mouth, swallow)

Dry swallow

With water

With a sucker

Encourage the patient to perform the cough suppression swallow at any sign of a

cough. Even if its just a small tickle. Tell them not to wait until the irritation is severe

enough to cause the coughing.

(Vertigan, 2008)

Relaxed Throat Breath

Inhale with relaxed throat

Tongue on floor of mouth

Lips gently closed

Jaw gently released

Relaxed throat breath con’tExhale on gentle /s/ with abdominal support, or /sh/ or /f/ in public

Hand on abdomen (above the belt, below the belt or both)

Inhale into abdomen- the abdomen comes in

Exhale from abdomen- abdomen comes in

As you pull in abdomen, exhale on gentle /s/

If more comfortable, use gentle sip of inhale and gentle blow for exhale,

feeling the air on the lips.

(Blager, 2008)

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Pursed Lip Breathing

Breathe in through your nose (as if you are smelling something) for about 2 seconds.

Pucker your lips like you're getting ready to blow out candles on a birthday cake.

Breathe out very slowly through pursed-lips, two to three times as long as you breathed in.

Repeat.

Distraction Techniques to Control Cough

Distraction

Chewing gum

Swallow your saliva

Eat moist food

Sip Water

Suck on ice chips

Wait five seconds and see whether the urge passes

Vocal Health Guidelines for Cough

Seven Ways to reduce irritation that causes coughing:

1. Avoid exposure to smoke

2. Breathe through your nose

3. Minimize intake of dehydrating substances

4. Lifestyle strategies for reflux

5. Inhale steam

6. Drink adequate quantities of water

7. Suck on non-medicated lozenges

Management of Reflux

-Patient Education

difference between LPR and GERD

Review pH probe findings

Use of PPI’s and H2 Blockers- pros and cons

LPR Guidelines

LPR Guidelines

Avoid juices, soda’s, alcohol, chocolate, vinegar based products, fatty foods, spicy foods

Do enjoy lean meats, vegetables, fruits, nuts/seeds, whole grains, olive oil, water

“Diet” of choice – Mediterranean Diet

Elevate the head of your bed 2-3 inches

Eat before 7:00 pm- do not lie down for at least 2 hours after each meal

Casually walk for 5 to 10 minutes after each meal

Psychoeducational Counselling

Success of intervention is dependent upon patient compliance.

Psychoeducational counseling aims to:

1. Increase adherence and motivation of treatment strategies

2. Facilitate the patient’s acceptance of the behavioral approach

3. Validation of condition- words of affirmation that they are not

malingering

4. Appropriate referrals made if emotional issues are triggered

(Vertigan 2012)

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Laryngospasm

Sudden onset

forceful contraction of the laryngeal sphincter

resulting in airway obstruction or complete

glottic closure and apnea for up to 20 seconds

Considered Emergent

Pursed Lip Breathing

Encourage the patient and those in immediate surroundings to remain calm

Patient sits and leans slightly forward at the waist

Small breaths in through the nose (place finger beside nares and feel air movement)

Small exhale through rounded (pursed) lips

Have patient perform this for 2- minutes.

Encourage them to NOT swallow or attempt to talk to while performing

Straw Breathing

Patient breaths in and out through straw cut in half or cocktail

size straw for 2-5 minutes.

Same principles apply as pursed lip breathing:

Remain Calm

No talking

No swallowing

Test after 2-5 minutes with /mmm/ 4x . If patient is able to

vocalize without difficulty breathing then they may swallow and

talk normally. The most likely will experience hoarseness after

episode but this should pass in several hours.

Paradoxical Vocal Cord Movement

PVCM is a laryngeal disorder that affects respiratory function through obstructing the airway in the closing or partial closing of the vocal folds during inspiration.

This will have a direct impact on breathing and voice production.

(Murry, Sapienza 2010)

Common Symptoms of PVCM

Throat clearing Throat mucus

Hoarseness Annoying cough

Something sticking in the throat

Breathing difficulties Coughing after lying down

Heartburn/chest pain Difficulty swallowing

(Murray, Sapienza 2010)

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Example of straw breathingBehavioral Management of PVCM

Respiratory Retraining

-Quiet rhythmic breathing

Exhaling w/shoulders relaxed, abdominal movement in/out consistent w/continuous exhalation/inhalation

-Breathing w/vocal resistance

Exhaling while sustaining /sh/, /f/, /z/ for increasing lengths of time

-Pulsed exhalation

Produce pulse of air using /ha/ or /sha/ followed by sniffing in through the nose w/closed mouth

-Abdominal focus at rest

Lie flat w/small book on stomach, focus on elevation of book w/inhalation and lowering of book w/exhalation; when successful, straw breathing initiated to increase resistance while focusing on abdominal movement; exercise expanded to include sitting/standing.

(Murray, Sapienza, 2010)

Respiratory Retraining Con’t

In addition to use of Murry/Sapienza’s strategies, train patients in

additional patterns of modified respiration

-In/Out through nose

-In through nose, out through pursed lips

-In/out through pursed lips

-In through nose, out through straw

-In/out through straw

-Sniff in x2/out through pursed lips/straw (vary length/bore of

straw to increase/decrease resistance as needed by the patient)

-Swallows (Saliva, liquids, wet snacks, etc.)

Respiratory Retraining continued

-All exercises practiced in one-minute increments

Reduces patient boredom

Allows for Patient control over laryngeal function repeatedly during the

day

-Exercises #1-5 practiced 2x/day for 3 weeks

-Exercise #6 practiced 10x day for 3 weeks

1st week in isolation ( no distractions), always sitting down, using clock as

timing device

Emphasize slow emptying of lungs during exhalation before repeating

sequence to minimize risk of hyperventilation

Monitor # of repetitions achieved in one minute

Respiratory Retraining Con’t

-Week # 2

Pattern of sniff/blow transitioned into activities of daily living (not driving at this time)

Focus now on practicing # of repetitions 10x/day

Maintain focus of complete exhalation before beginning new repetition

Week 3

As above but pattern can now be practiced while driving

Respiratory Retraining Con’t-Week # 4 and beyond

Patient begins to experiment with all of the above techniques

during episodes of cough or PVCM (determine which strategy

(ies) are most beneficial in managing episodes)

Continue to maximize patient adherence to other interventions

Schedule therapy sessions at 4, 6, 8, and 12 weeks

If progress demonstrated by 12 week mark, gradually

schedule f/u at greater intervals or discharge

If not, f/u at 4 week intervals; recommend f/u with referring

physician

(Haxer, 2009)

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Treatment for Hoarseness as Result of

ILS-Stretch Flow exercises

Cup Bubble blowing

Straw Phonation

-Resonant Voice Techniques

-Vocal Rest/Confidential Voice if patient presents with TVC ulcers or

hemorrhage from chronic cough/throat clearing behavior

-Vocal Function Exercises

Case Studies

Case Study 1

MR - 48 yo female who is a professor at small college

Presents as a new patient to Voice Clinic with a 1 year

hx of right arytenoid granuloma and vocal fatigue

Laryngeal videostroboscopy shows left TVC paralysis,

muscle tension dysphonia, diffuse edema, R arytenoid

granuloma

Mild breathy vocal quality with decreased intensity

VHI-16 MPT -12

Recommended pH probe, voice therapy, placed on PPI

Case Study con’t

Patient did not return for further testing or voice therapy

She returns to us 3 years later with same presentation and the addition of

laryngospasms, lump/tightness in throat, sharp shooting pain with speech

Her voice issues directly affecting her job performance- professor and has

advanced to President of the College. Heavy voice user

Plan: pH probe, voice therapy, Gabapentin 200 mg at bedtime; 100 mg at

breakfast. Patient chose to avoid Gabapentin-concern for side effects

pH probe showed significant LPR-treated with 40mg PPI bid

Voice therapy initiated- respiratory exercises for laryngospasm, cup bubble

stretch/flow exercises, straw phonation to break tension followed by 12

weeks of Stemple’s Vocal Function Exercises to address vocal fatigue

Following PPI treatment, GI workup and voice therapy she had resolution of

symptoms

MRFebruary 2015

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Case Study 2-EW

17 yo female-runner

Having episodes while running of tightness in throat followed by

difficulty breathing and excessive foamy mucus in her throat that

forces her to stop running. Odors will trigger tightness in throat

when not running as well as stress.

The episodes happen when she is practicing or competing.

Worsening of symptoms during competition.

Had an episode at a track meet and ended up at ACH where she

underwent a full cardiac and allergy workups that were both (-).

She denies dysphagia and heartburn but positive for hoarseness

after running and belching.

Case Study 2 con’t

Laryngeal videostroboscopy showed mild diffuse edema. Subtle weakness of

left TVC but no paralysis. Asymmetric vibratory wave with good glottic

closure and supraglottic tension.

Plan: pH probe, Gabapentin, Voice therapy

pH probe showed LPR-placed on PPI bid and alginate (Gaviscon Advance)

Voice therapy- PVCM breathing tech, pacing with running (worked with

coach), straw breathing, Vocal health to include hydration and LPR guidelines,

counselling (asked mom to leave the room for few minutes).

Complete resolution of symptoms- patient weaned off meds after 3 months.

She continued to run and had the fastest 2 mile run in state history. Full track

scholarship to UCA

EW

Bibliography

Blager, F.B. (2000) ‘Paradoxical vocal fold movement: Diagnosis and management’, Current Opinion in

Otolaryngology & Head and Neck Surgery, 8(3), pp. 180–183. doi: 10.1097/00020840-200006000-00009.

Bolser, D.C. (2010) ‘A streetcar named urge-to-cough’, Journal of Applied Physiology, 108(5), pp. 1030–

1031. doi: 10.1152/japplphysiol.00177.2010.

Chamberlain, S., Garrod, R. and Birring, S.S. (2013) ‘Cough suppression therapy: Does it work?’,

Pulmonary Pharmacology & Therapeutics, 26(5), pp. 524–527. doi: 10.1016/j.pupt.2013.03.012.

Davenport, P.W. (2007) ‘Urge-to-cough: What can it teach us about cough?’, Lung, 186(S1), pp. 107–111.

doi: 10.1007/s00408-007-9045-7.

DICPINIGAITIS, P.V., RHOTON, W.A., BHAT, R. and NEGASSA, A. (2012) ‘Investigation of the urge-to-cough

sensation in healthy volunteers’, Respirology, 17(2), pp. 337–341. doi: 10.1111/j.1440-1843.2011.02094.x.

Gartner-Schmidt, J.L., Shembel, A.C., Zullo, T.G. and Rosen, C.A. (2014) ‘Development and validation of

the Dyspnea index (DI): A severity index for upper Airway–Related Dyspnea’, Journal of Voice, 28(6), pp. 775–

782. doi: 10.1016/j.jvoice.2013.12.017.

Gibson, P.G., Simpson, J.L., Ryan, N.M. and Vertigan, A.E. (2014) ‘Mechanisms of cough’, Current Opinion

in Allergy and Clinical Immunology, 14(1), pp. 55–61. doi: 10.1097/aci.0000000000000027.

Haxer, M. (2009) Chronic Cough. Available at: www.asha.org/Events/.../2011/Haxer.

Ibrahim, W.H., Gheriani, H.A., Almohamed, A.A. and Raza, T. (2007) ‘Paradoxical vocal

cord motion disorder: Past, present and future’, Postgraduate Medical Journal, 83(977),

pp. 164–172. doi: 10.1136/pgmj.2006.052522.

Marcinow, A.M., Thompson, J., Forrest, L.A. and de Silva, B.W. (2015) ‘Irritant-induced

paradoxical vocal fold motion disorder: Diagnosis and management’, Otolaryngology --

Head and Neck Surgery, 153(6), pp. 996–1000. doi: 10.1177/0194599815600144.

McCabe, D. and Altman, K.W. (2012) ‘Laryngeal Hypersensitivity in the world trade

Center–exposed population’, American Journal of Respiratory and Critical Care Medicine,

186(5), pp. 402–403. doi: 10.1164/rccm.201205-0808oe.

Morrison, M., Rammage, L. and Emami, A.J. (1999) ‘The irritable larynx syndrome’,

Journal of Voice, 13(3), pp. 447–455. doi: 10.1016/s0892-1997(99)80049-6.

Murry, T. and Sapienza, C. (2010) ‘The role of voice therapy in the management of

paradoxical vocal fold motion, chronic cough, and Laryngospasm’, Otolaryngologic Clinics

of North America, 43(1), pp. 73–83. doi: 10.1016/j.otc.2009.11.004.

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Ryan, N.M., Birring, S.S. and Gibson, P.G. (2012) ‘Gabapentin for refractory chronic

cough: A randomised, double-blind, placebo-controlled trial’, The Lancet, 380(9853), pp.

1583–1589. doi: 10.1016/s0140-6736(12)60776-4.

Shembel, A.C., Rosen, C.A., Zullo, T.G. and Gartner-Schmidt, J.L. (2013) ‘Development

and validation of the cough severity index: A severity index for chronic cough related to

the upper airway’, The Laryngoscope, 123(8), pp. 1931–1936. doi: 10.1002/lary.23916.

Vertigan, A.E. and Gibson, P.G. (2011) ‘The role of speech pathology in the

management of patients with chronic refractory cough’, Lung, 190(1), pp. 35–40. doi:

10.1007/s00408-011-9333-0.

Vertigan, A., Theodoros, D., Winkworth, A. and Gibson, P. (2007) ‘Chronic cough: a

tutorial for speech language pathologists.’, J Med Speech Language Pathol, 15, pp. 189–

206.

Widdicombe, J., Fontana, G. and Gibson, P. (2009) ‘Workshop – cough: Exercise,

speech and music’, Pulmonary Pharmacology & Therapeutics, 22(2), pp. 143–147. doi:

10.1016/j.pupt.2008.12.009.