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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 7-13

Irritable larynx syndrome (Internal and external correlates)


1 Phoniatric Unit, ENT Department, Faculty of Medicine, Assiut University, Assiut, Egypt
2 Department of ENT, Phoniatric Unit, Faculty of Medicine, Helwan University, Helwan, Egypt

Date of Submission02-Sep-2018
Date of Decision11-Sep-2018
Date of Acceptance12-Sep-2018
Date of Web Publication05-Feb-2020

Correspondence Address:
Amira H. Abd El-Aal Aref
Phoniatric Unit, ENT Department, Assiut University Hospital, Assiut 71516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCMRP.JCMRP_73_18

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  Abstract 


Irritable larynx is a condition of laryngeal dysfunction at which there is abnormal spasmodic closure of both vocal folds during inspiration. Patient complains of many symptoms as stridor, dysphonia, chocking, globus sensation, and dyspnea. These symptoms are not specific for irritable larynx only, but; they are frequently confused with other disorders such as gastroesophageal reflux, asthma, and different causes of chronic cough. The golden method for diagnosis is to visualize both vocal folds abducted during inspiration in acute attack by indirect laryngoscopy. To review recent available literature concerning irritable larynx syndrome to get essential recent data as a primary step for understanding this disorder.

Keywords: chronic cough, irritable larynx, paradoxical vocal folds motion, stridor


How to cite this article:
Abdel Haleem EK, Hassan ES, Yassen DG, El-Aal Aref AH. Irritable larynx syndrome (Internal and external correlates). J Curr Med Res Pract 2020;5:7-13

How to cite this URL:
Abdel Haleem EK, Hassan ES, Yassen DG, El-Aal Aref AH. Irritable larynx syndrome (Internal and external correlates). J Curr Med Res Pract [serial online] 2020 [cited 2020 Feb 19];5:7-13. Available from: http://www.jcmrp.eg.net/text.asp?2020/5/1/7/277500




  Introduction Top


The larynx is a luxuriously innervated structure and in humans plays a basic role in subserving several basic biological functions; such as the facilitation of swallow, communication, and airway protection[1]. Its anatomical site supports its role as a true 'gateway' to the airways and effective complex reflex mechanisms that prepare the larynx to be in a state of readiness for closure, that is as a protective defensive function [2–4].

Different terms have been utilized to describe a syndrome accompanied with hyperfunctional laryngeal behaviors marked by acute upper airway obstruction with coexisting dysphonia, aphonia, dyspnea, dysphagia, cough, laryngeal stridor, laryngeal muscle tension patterns, and a host of several other physical and nonphysical symptomatology as paradoxical vocal cord movement [2–4], functional airway obstruction[5], factitious asthma[6], paradoxical vocal cord dysfunction (PVCD/VCD) exposed as asthma[7], Munchausen's stridor, laryngeal spasm like a bronchial asthma[8], functional upper airway obstruction, exercise-induced laryngospasm, stridor due to vocal fold malfunction related to psychological factors[9], psychogenic stridor[2], episodic laryngeal dyskinesia[10], episodic paroxysmal laryngospasm[11], a functional laryngeal stridor[12], and the irritable larynx syndrome (ILS)[13].


  Incidence and Prevalence Top


The incidence of VCD in the general population in 1999 was measured at 3%, but rates have been reported as high as 26.9% in 2007[14]. The VCD patients are typically presented as 20–40 years old and female with multiple life stressors[2],[3]. Approximately one-third of cases among adolescents are males[16]. Prevalence has been reported to range from 2.5% of patients seeking asthma clinic to up to 22% of patients with recurrent emergency department visits for dyspnea[2],[3].


  Pathophysiology Top


Vocal folds normally abduct during inspiration, expanding the glottis (opening between the vocal folds) and adduct during exhalation. Glottis size is controlled by voluntary and reflex acts, with the fundamental task of defensing the airway. Vocal folds permit air to reach the lungs during inspiration[19]. The pathophysiology of VCD is not sufficiently studied but is thought to be a consequence of laryngeal hyperresponsiveness and paradoxical vocal fold closure during inspiration and may be worsened by psychological tension[18]. In VCD, the vocal folds adduct or close during inspiration, decreasing entered inspired air and producing an inspiratory stridor basically over the larynx[2],[3].

Once thought to be an essentially psychogenic disease, the ILS becomes presented as a functional disorder that may be relevant to the role of glottis closure in securing the trachea and lungs. Neural malfunction presented as abnormal laryngeal hypersensitivity and reflux, motor neural dysfunction, inflammatory process, and neuroplastic changes to brain stem governing center of larynx have been proposed as mechanisms leading to the ILS. In spite of the fact that there is a group of patients in whom paradoxical vocal fold motion (PVFM) likely represents a conversion disorder, most patients suffer from other medical conditions, for example, asthma, irritant exposures, gastroesophageal reflux disease, exercise intolerance, and viral illness[21].


  Etiology (Poorly Understood) Top


Psychogenic causes, conversion reaction (70%) and functional, idiopathic, and nonorganic causes have been proposed by researchers to explain functional stridor, laryngeal muscle tension patterns, aphonia[2],[4],[9],[22],[23],[24],[25], and dysphonia. Some authors relate the onset of paradoxical vocal cord movement and ILS with upper respiratory viral infections[2],[3].

Over the previous decade, more confirmation has been set on distinguishing other likely precipitating or exacerbating organic etiological variables associated with this syndrome manifestations allergic phenomena, gastroesophageal reflux disorder (63–80%), respiratory type of laryngeal dystonia, drug-induced laryngeal dystonic reactions as neuroleptic drugs like haloperidol, chlorpromazine, and thiopental and other neurologic pathophysiological mechanisms (that affect brain stem as  Chiari malformation More Details, hydrocephalus, meningomyelocele, cerebrovascular accidents, and severe closed head injuries)[2].

Upper esophageal inflammation resulting from acidic reflux activates mucosal chemoreceptors, superior laryngeal innervation of larynx, and vagus-mediated nerve networks[2].


  Clinical Presentation and Diagnosis Top


Symptoms

Patients report a sudden onset of symptoms as shortness of breathing, cough, throat tightness, change of voice, wheezing, chocking sensation, heaviness, globus sensation (lump in the throat), and dyspnea on exertion. These symptoms usually occur as episodes or recurrent attack and sudden onset[16],[19],[26].

Triggers

Fumes, dust, chemical products, smoking, psychological tension, and strenuous exercise[15],[16],[18],[27].

Laryngoscopic examination

During attack

  1. No organic disease.
  2. Vocal fold adduction during inhalation:


    1. Mild: minimal movement.
    2. Moderate: vocal folds go to midline without touch.
    3. Severe: vocal folds touch.


  3. A posterior 'diamond-shaped chink' on examination with a laryngoscope[28]. With laryngoscopy, vocal fold adduction can be seen on inspiration[2],[3].
  4. Lateral constriction.


In between attacks

No abnormality detected.

Voice abnormalities in ILS according to auditory perceptual assessment of voice, stroboscopy, acoustic analysis, and aerodynamic measurement.

As regard auditory perceptual assessment

Dysphonia, strained irregular, and low pitched voice[30].

Stroboscopic finding

Using stroboscopy there is decreased mucosal waves and phase asymmetry[31].

Acoustic assessment

Reduced harmonic to noise ratio and increased jitter[32].

Aerodynamic measurements of voice

Maximum phonation time is much shorter than normal[2],[3].

Additional investigations

  1. Pulmonary Function Test.
  2. The Pittsburgh Vocal Cord Dysfunction Index.
  3. Methacholine Challenge Test.
  4. Exercise Provocation.
  5. Laboratory studies may be indicated to exclude other diagnoses including:


    1. Eosinophil count.
    2. Eosinophilia.
    3. Serum immunoglobulin E assay.
    4. Arterial blood gases.
    5. C1 inhibitor and C4 levels.


  6. Chest radiography.
  7. Allergy skin testing.


Differential diagnosis is shown in [Table 1].[13],[34],[35]
Table 1: Differential diagnosis of laryngeal movement disorders

Click here to view


Work-associated irritable larynx syndrome

Workers usually are subjected to laryngeal stimuli and strong fumes; therefore, the workplace can precipitate symptoms of ILS in exposed humans[13].

Modified Morrison's criteria for work-associated irritable larynx syndrome

Acute manifestations owing to laryngeal and/or supraglottic spasm:

  1. Major symptoms:


    1. Dysphonia.
    2. Inability to take a breath.


  2. Minor symptoms:


    1. Foreign body sensation at the level of throat.
    2. Chronic cough (CC).


  3. Presence of a 'workplace' irritant stimuli:


    1. Airborne chemicals and fumes.
    2. Confirmation of laryngeal spasm and elimination of organic laryngeal pathology by phoniatrics clinic.


Probable' work-associated irritable larynx syndrome = 1 (at least one major symptom)+2.



Definite' work-associated irritable larynx syndrome = 1 (at least one major symptom)+2 + 3[13].

Paradoxical vocal fold motion disorder in children presenting with exercise-induced dyspnea

There are two different forms of paradoxical vocal fold motion disorder (PVFMD): spontaneous and exercise-precipitated. Spontaneous PVFMD occurs suddenly and without any precipitating factors, while exercise-precipitated PVFMD is precipitated by heavy exercise[36]. The spontaneous PVFMD, the diagnosis is based fundamentally on detailed history giving its random and unstimulated course. Further work-up may include direct visualization of the vocal folds, assessment of pulmonary function tests, and speech pathology examinations[37].


  Clinical Presentation Top


Symptoms during or following exercise include:

  1. Chest tightness.
  2. Cough.
  3. Shortness of breath.
  4. Wheeze.
  5. Underperformance or poor performance on playground.
  6. Fatigue.
  7. Prolonged recovery time from exercise exhaustion.
  8. Gastrointestinal discomfort[28],[37],[38],[39],[40],[41].


The relationship between chronic cough and paradoxical vocal fold movement

The relationship between CC and PVFM is unclear and may be viewed from several perspectives. First, cough may be considered a symptom of PVFM. Second, there may be a causal relationship between CC and PVFM. Third, CC and PVFM may be considered to be separate but coexisting entities [Table 2][42].
Table 2: Comparison of chronic cough and paradoxical vocal fold movement[42]

Click here to view


Laryngopharyngeal reflux/gastroesophageal reflux disease

We should differentiate between these two terms:

  1. Laryngopharyngeal: means a location/site of hypopharynx.
  2. Gastroesophageal: means a motion of gastric content to esophagus, that is, 'directional prescription'[43].


Clinical outcome

Clinical presentations and complications of the two types of reflux are quite different:

  1. The gastroesophageal type has: heart burn, gastritis, erosive esophagitis, esophageal stenosis, precancerous forms; Barrett's metaplasia, and, adenocarcinoma[44].
  2. The extraesophageal laryngopharyngeal/hypopharyngeal reflux may show:


    1. Bronchial: asthma with related symptoms, oropharyngeal dysphagia[45].
    2. Laryngeal: this is sometimes coined as 'reflux laryngitis'[46].


Symptoms

Lump sensation, voice changes[47], hemming, and hawking.

Signs

Redness of both arytenoids, vocal processes, and less frequently contact granuloma[1],[48],[49],[50],[51],[52],[53].

Irritable larynx syndrome treatment

  1. In acute attacks.


  2. Medical treatment (70% helium and 30% oxygen mixture):

    This therapy consists of administration of a helium–oxygen mixture (heliox), which is less dense than air and thus reduces the turbulence in the airway during inspiration.

    Heliox inhalation just produces a temporary effect in the emergent management of acute ILS[54].

  3. In between attacks:


    1. Asthmatic treatment.
    2. Proton pump inhibitors.
    3. Antihistaminic medications.
    4. Antianxiety medications, hypnotics.
    5. Organic abnormalities correction.
    6. Psychotherapy.
    7. Reassurance.
    8. Self-awareness of breathing sequence.
    9. Voice therapy (behavioral therapy).
    10. Botox injection[55].


    Medical care

    A multidisciplinary approach with a physician and speech therapist and a psychiatrist, if needed, is usually effective[55].

    Psychotherapy

    According to a systematic review of psychological interventions for patients with VCD, techniques such as psychotherapy, behavioral therapy, use of antianxiety, and anti-depressant medications, and hypnotherapy in conjunction with breathing exercises may be effective treatment methods[56].

    Anticholinergic agent

    Inhaled ipratropium may be helpful treatment in patients with exercise-induced VCD[2],[3].

    Botulinum toxin

    An intralaryngeal injection of botulinum toxin relieves symptoms by blocking acetylcholine release at the motor end plate and creating a laryngeal muscle weakness, thus facilitating inspiratory and expiratory airflow[58].

    Topical lidocaine

    The mechanism of action is to break the cycle of hyperactive glottal and supraglottic muscle contractions[59].

    Voice therapy

    The mainstays of treatment for VCD involve teaching the patient vocal fold relaxation techniques and breathing exercises. These procedures have been very successful and are used concomitantly with psychological support in difficult cases[60].


      Relaxed Throat Breathing Exercises Top


    Technique

    1. Sip water before and after doing these exercises.
    2. Exercises:


      1. Shoulders down:


      2. This is the cue to relax.

      3. Hands on abdomen:


      4. This helps you focus on easy abdominal breath support (the best and the most relaxed way to breath).

      5. Gentle quick 'sip' of air in (pursed lip 'sip, sip, sip'):


      1. Breathe in through your mouth (using a straw cut to 3' is helpful but just posing your lips can work also).
      2. Pursed lips around the straw.
      3. About 1 s for the inhale.


    3. Gentle blow of air out (blow, blow, blow):


    1. Through the slightly tight lips around the straw.
    2. About 2–3 s for the exhale.
    3. Breathing both in and out should be easy and relaxed.


  4. Practice 10 breaths five to seven times per day when you are not having symptoms. For example; in the car: when reading, watching, television or before medications. Regular practice when you are feeling well is important.
  5. Be patient when completing the breathing. It may take several minutes to start feeling relief.
  6. Make it automatic and use it at the firstt sense of throat tightness to prevent or suppress the VCD. You may start with the inhale or the exhale.
  7. If asthma is also a concern, follow your physician's instructions regarding taking an inhaler after completing the breathing exercises.
  8. Use it to 'pre-treat' yourself before known trigger for VCD. Possible triggers be: changing in air temperature, strong odors or perfumes, and exercise.
  9. This technique can be a 'stress buster' too[2],[3].



  Voluntary Resistive Breathing Top


  1. Hold the jaws together.
  2. Pretend to suck through a straw (inhale to the maximum capacity and immediately reverse the procedure to exhale).
  3. Do this procedure at the moment they experience the pre-episode tension in the larynx and neck.
  4. Do the exercise no more than three times and then provide a rest period of no less than 3 min.


Behavioral management of persistent chronic cough and paradoxical vocal fold movement

Vertigan[62] described a treatment program that had four main components, including behavior modification, cognitive adjustment, vocal hygiene, and facilitation of efficient voicing.

Management of laryngo/esophageal reflux disease

PPI is the usual treatment of 'reflux laryngitis.' Despite some recorded positive therapeutic results, this treatment is given on empirical bases[63]. The exclusion of a possible placebo effect cannot be ruled out. The efficacy of such a treatment is not tested[64],[65],[66],67]. Some studies showed that PPI treatment may be inferior to simple measures as modifying life style. The role of noninvasive measures such as behavior readjustment voice therapy is not discussed as a possible line of treatment[68]. Behavior readjustment voice therapy proved to be effective in the management of many of the manifestations attributed to laryngopharyngo reflux disease[69],[70],[71].


  Summary and Conclusion Top


The larynx plays many roles including respiratory modulation and airway protection. Therefore, it is no wonder that the multifunctioning larynx, when exposed to any number of endogenous and exogenous stimuli, can cause perplexing clinical feature variants.

Adductor spasm of the larynx may be triggered by an excessive response to external and internal airway stimuli such as smoking, dust, fumes, and postnasal discharge.

The clinical history provides a limited opportunity to distinguish between patients with VCD and patients with asthma because both groups present with symptoms of wheezing, cough, and dyspnea. The localization of airflow obstruction to the laryngeal area is an important clinical discriminatory feature in patient with VCD.

Another clinical clue: patients with VCD often have poor response to beta agonists or inhaled corticosteroids.

The hallmark of diagnosis is noted on direct and indirect laryngoscopy; a Glottic Chink is present along the posterior portion of the vocal folds while the anterior portion of the vocal folds is adducted.

Several conditions may deteriorate voice quality in ILS including laryngeal, structural abnormalities neurological impairment, and comorbid diseases, for example, asthma, CC, and reflux.

Most of laryngeal manifestations of laryngopharyngo reflux disease are nonspecific to the claimed causal agent. These symptoms and signs may be a part of other categories of voice disorders where no reflux is encountered.

Voice therapy is a very important measure to be done including breathing exercises. Sometimes, intermittent positive pressure ventilation therapy and respiratory training may give good results in unresponsive patients.

Recommendations

Further researches to reveal the proper pathophysiology to clarify more about this poorly understood topic are needed. Behavioral treatment for ILS is a promising option for patients who have failed medical management. However, the efficiency of this option for ILS, it requires further exploration using well-defined randomized controlled treatment trials.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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