Voice and Upper Airway Symptoms in People With Chronic Cough and Paradoxical Vocal Fold Movement
Introduction
Chronic cough (CC) and paradoxical vocal fold movement (PVFM) are significant clinical problems that may present to a variety of health professionals, including otolaryngologists, speech language pathologists, and respirologists. Although there is theoretical support for a relationship between CC and PVFM,1, 2 there has been no systematic comparison of these two conditions in terms of their symptom profiles and their underlying mechanisms. Furthermore, despite recent literature suggesting a possible link between CC and PVFM,1, 2, 3 there is currently no model conceptualizing a link between these two conditions, and most studies have examined the two conditions as discrete entities.
The description of symptoms evident in CC and PVFM helps to define these conditions. With the exception of French et al,4 who documented voice-related side effects of CC, most CC literature describes cough but does not explore other coexisting upper airway symptoms such as dysphonia and globus pharyngeus. Although symptoms in PVFM have been described more frequently in the literature than those for CC, these reports did not compare PVFM with any other group, and therefore, the characterization of these conditions remains unclear. A prospective comparison of the symptoms and descriptive features of CC and PVFM conducted in comparison with other related laryngeal conditions or healthy controls has not been reported, but such a comparison would clarify the relationship between CC and PVFM.
There is preliminary evidence that speech pathology (SP) management for CC that is refractory to medical treatment can assist people to gain control over their symptoms.5, 6 However, the specific cough characteristics, such as timing, triggers, and voluntary control of CC refractory to medical treatment, have not been explored in detail nor has the theoretical basis for SP management of CC been investigated. Previous studies of CC found that the most frequent descriptive characteristics of cough were productive, dry,7, 8 barking, or honking,9, 10, 11 whereas the most frequent patterns were paroxysmal and self-propagating.7, 8 Creer et al12 described a case of an adolescent boy with CC presumed to be due to attention-seeking behavior and who had been expelled from school because of the cough. The cough was described as loud, grating, and occurring in uncontrollable bouts lasting for several seconds. Many of these reports were case studies or involved small subject numbers,13 and they contained limited systematic evaluation of the cough. Furthermore, these studies did not describe other related symptoms such as dysphonia and dyspnea and did not employ comparison groups. Mello et al7 concluded that the character or timing of the cough had limited diagnostic value. Despite this conclusion, a description of cough characteristics in refractory CC might provide a starting point for developing behavioral treatment programs.
A variety of triggers have been reported for CC, including talking,2, 14, 15 exercise,14 laughing,2, 14, 15 and cold air.14, 15, 16 These triggers are similar to those reported for PVFM and the Irritable Larynx Syndrome;2 however, triggers for CC and PVFM per se have not been systematically compared. The afferent limb of the cough reflex is variable both in nature and in site, which accounts for the large spectrum of physiological and pathological events that can precipitate cough.17 Cough receptors in the larynx tend to be more mechanosensitive, whereas those in the distal bronchial airway tend to be more chemosensitive.16 It is hypothesized that people with bronchial hypersensitivity might have more chemical triggers and those with extrathoracic sensitivity have more mechanical type triggers. Buddiga18 hypothesized that mediation or stimulation of the vagus nerve may alter laryngeal tone and lower the threshold for stimuli to produce vocal cord spasm or precipitate the abnormal adduction of the vocal folds.
People's perception of their ability to control cough is a significant factor in understanding CC. The importance of patients learning to consciously control their cough has been emphasized as an essential component of behavioral management.1, 5, 19 Although studies have reported on voluntary control of acute cough,20, 21 a significant omission in current research literature is that no studies have reported on voluntary control of CC. Specifically, there are no descriptions of the perception of voluntary control over the cough, the strategies used in attempt to control the cough, or the effectiveness of those strategies. Yet these are key factors in helping the patient gain control and reduce the frequency and severity of cough.
Altman et al16 claimed that reflexive cough is a stronger model for the complex interplay between the sensory and the motor mechanisms producing cough. In other words, the reflexive mechanisms underlying cough control are stronger than the voluntary mechanisms. It could be assumed, therefore, that despite the potential for people to develop voluntary control over their cough, in many cases, reflexive control of cough could predominate over cortical control. The model proposed by Lee et al21 indicated that the mechanisms of cough are both voluntary and reflexive. These suggestions are consistent with Hutchings et al,20 who concluded that the cough can be initiated at will and be voluntarily suppressed. Lee et al21 believed that the implications of their proposal were that antitussives in cough associated with upper respiratory tract infection might work at the level of the cerebral cortex as well as at the level of the brain stem. These papers provided theoretical support for the concept of voluntary control of CC, which is an important factor underpinning behavioral management of this condition.
Voice symptoms have been reported in both CC and PVFM. Morrison et al2 hypothesized a link between voice disorders and the conditions of CC and PVFM, although the relationship has not been confirmed.22 Voice symptoms and hoarseness have been conceptualized as side effects or coexisting symptoms in CC4 and PVFM,2, 16 whereas coughing and throat clearing are often regarded as symptoms in some functional voice disorders such as muscle tension dysphonia.23 It has not been established, however, whether the voice symptoms in CC and PVFM are typical of those found in functional voice disorders and whether coughing and throat clearing behaviors in voice disorders are similar to those occurring in CC and PVFM. A further comparison of symptoms in CC and PVFM with those occurring in voice disorders is needed to further differentiate these conditions.
The aim of this study is to understand the conditions of CC and PVFM at the level of the symptom profile. It is hypothesized that there is considerable overlap in symptoms in PVFM, CC, and some functional voice disorders. To test this hypothesis, this study aimed to:
- 1.
Comprehensively describe and compare medical history, psychological characteristics, and respiratory, voice, cough, and upper airway symptoms in people with PVFM and CC and determine the degree of overlap between the two conditions.
- 2.
Compare the symptoms and descriptive characteristics of CC and PVFM with a group with functional voice disorders.
- 3.
Compare the symptoms and descriptive characteristics of CC and PVFM with a group of normal controls.
Section snippets
Methodology
The study involved an assessment consisting of medical, voice, cough, and respiratory history, and patient symptom ratings, administered by a qualified speech pathologist with experience treating voice disorders.
Medical history
The medical history for the five participant groups is summarized in Figure 1. There was no significant difference in the prevalence of PND among the Cough + PVFM, PVFM Alone, Cough Alone, or Voice Disorders groups (P = 0.55); however, the prevalence of PND was significantly higher in these groups than in the normal controls (P = 0.003). Participants in the Cough + PVFM, PVFM Alone, and Cough Alone groups had a higher prevalence of GER symptoms than those in the Voice Disorders (P = 0.004) and
Discussion
A major finding of this study was the consistent overlap between the Cough + PVFM and Cough Alone groups on all symptoms and cough characteristics. Information pertaining to the cough characteristics of participants in the Cough + PVFM, Cough Alone, and Voice Disorders groups would seem to provide important information for speech pathology management of these conditions. The clinical groups had significantly higher symptom ratings and anxiety scores than the normal controls but similar
Anxiety and depression
Psychiatric factors have been considered in patients with PVFM and CC that occur in the absence of an identified medical cause. However, in the current study, no significant psychiatric symptomatology was found. Although persons were identified with probable anxiety or depression, the mean scores were within the normal range for most groups. These findings are consistent with some previous reports that found higher anxiety levels in people with PVFM but no difference in family functioning scores
Clinical implications of the cough characteristics
Behavioral treatment options for CC and PVFM have been described previously.5, 42, 47, 55, 56 It would seem, however, that specific characteristics of the cough symptoms could further refine and individualize behavioral treatment plans for people with CC. For example, clinical experience has shown that people with a dry irritated cough usually acknowledge there is a problem in the throat and accept that their cough is not beneficial to them. Those with productive cough triggered from the chest,
Conclusion
Three main conclusions may be drawn from the data in this study. The symptom profiles identified three categories of disorder, including cough with or without PVFM, PVFM Alone, and Voice Disorders. Although PVFM Alone and Voice Disorders are distinct entities, there is some overlap among the conditions of voice disorder, PVFM, and CC. There was also a high prevalence of upper airway symptoms in every participant group. These results challenge current thinking that CC and PVFM are discrete
Acknowledgments
The authors would also like to acknowledge the following staff from John Hunter Hospital for their assistance with data collection: Mr. Trevor Borgas, Senior Hospital Scientist; Dr. Colin Reid, Otolaryngologist; Ms. Larissa Mason, Speech Pathologist; and Mr. Matthew Frith, Speech Pathologist. Finally the authors would like to acknowledge the assistance of Dr. Jodi Simpson, Hunter Medical Research Institute, for assistance with graphical design.
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Supported by a grant from Jennifer Thomas through the Hunter Medical Research Institute.