The relationship between chronic cough and paradoxical vocal fold movement: a review of the literature

A comparison of two approaches to the treatment of chronic cough: perceptual, acoustic, and electroglottographic outcomes

Voice problems have been reported to occur in association with chronic cough (CC) and can interfere with quality of life. Voice symptoms can improve following behavioral intervention for CC that persists despite medical management; however, formal measures of voice changes have not been reported. The aim of this study was to measure the changes in perceptual, acoustic, and electroglottographic voice characteristics after a SPEech Pathology Intervention Program for CHronic Cough (SPEICH-C) compared to a Healthy Lifestyle Education intervention program (HLE control). Eighty-two participants with CC that was refractory to medical management were randomly allocated to receive either the SPEICH-C or an HLE control. Participants in the SPEICH-C group demonstrated a significant reduction in perceptual ratings of breathy, rough, strain, and glottal fry qualities (P<0.001) in comparison to the HLE control group. There was a significant improvement between pre- and postintervention maximum phonation time, jitter, and harmonic-to-noise ratio values in the SPEICH-C group; however, the magnitude of change was not significantly different between groups. There was no significant change in fundamental frequency, standard deviation of fundamental frequency, phonation range, or closed phase of vocal fold vibration after intervention for either group. These results demonstrated that SPEICH-C can improve perceptual aspects of voice quality suggesting that dysphonia may be a fundamental characteristic of CC.

A review of voice and upper airway function in chronic cough and paradoxical vocal cord movement

PURPOSE OF THE REVIEW

Chronic cough and paradoxical vocal fold movement (PVFM) are perplexing conditions. This paper reviews the recent literature in relation to the nature of PVFM and chronic cough and the management of symptoms associated with these disorders.

RECENT FINDINGS

There are similarities in the voice and upper airway symptoms in chronic cough and PVFM. Clinically significant voice symptoms are present in approximately 40% of individuals with chronic cough and PVFM and are similar to those occurring in voice disorders such as muscle tension dysphonia. Chronic cough can be associated with PVFM in a large proportion of cases. Extrathoracic airway hyperresponsiveness is a common underlying mechanism in PVFM and chronic cough. Speech pathology intervention can be effective in controlling symptoms in chronic cough, which suggests that the anatomic diagnostic protocol could be expanded to incorporate this intervention. Chronic cough that fails to respond to medical management should be conceptualized as either due to PVFM or idiopathic. PVFM and chronic cough are not necessarily the result of underlying psychopathology.

SUMMARY

Chronic cough and PVFM manifest in a range of clinically significant voice and upper airway symptoms. The anatomic diagnostic protocol used in the management of chronic cough could be expanded to include PVFM as a potential cause of cough, and speech pathology intervention as treatment for chronic cough.

Self-reported voice-related quality of life in adolescents with paradoxical vocal fold dysfunction

Paradoxical vocal fold dysfunction (PVFD) is a complex disorder of the larynx that primarily affects breathing. To date, no study has focused on the patient's own perception of how their quality of life related to voice is affected by the diagnosis of PFVD. The objective of this study is to characterize the self-reported voice-related quality of life (VR-QOL) patients diagnosed with PVFD using the Pediatric Voice Outcomes Survey (PVOS) instrument; an additional objective was to assess for the presence of any associations between laryngeal findings, concomitant medical disorders, and PVOS measures. The method used was a retrospective chart review. Twenty patients are identified in the study period; there were 17 females (mean age 14 years) and three males (mean age 11 years). The mean PVOS scores are uniformly normal for the subset of boys (n=3, mean PVOS 100). The mean PVOS for the 17 females was 89 (SD, 12.8), lower than that measured in healthy, age-matched females (n=13) who had a mean PVOS of 95 (SD, 7.4). The difference between these two groups was not statistically significant (P<0.17, unpaired t test). Although the absolute PVOS scores were affected by observed laryngeal abnormalities, asthma history, or reflux history, the absence of any of these were significantly more likely to be associated with a perfect score on the PVOS. The overall PVOS does not show a significant decline in the self-reported VR-QOL. Several cofactors may be associated with the detectable but not significant reduction in the PVOS scores for the females in this study.

Cough throughout life: children, adults and the senile

We review cough from premature birth, mature neonatal life, in childhood and adult life, and in old age. There is a regrettable lack of definitive studies, but many clues in the literature. The cough reflex seems weak in premature infants, but develops with maturity. It is pronounced in childhood, but there seem to be no studies comparing its strength then with that in adulthood. In old age the cough may weaken, as indicated by the prevalence of aspiration pneumonia. These changes are presumably related to the development and degeneration of the afferent and central nervous pathways for cough, which may be reflected in the changes in laryngeal muscle function with age. There is much evidence that age influences the development of the respiratory system in general, and of the immune system which would affect the degree, frequency and clinical issues of cough. Other factors that limit our understanding of the changes in cough with age include the reporting of cough by parents in infants and carers in old age and the use of different diagnostic criteria throughout life. Age-related variation in cough sensitivity seems to be well established, but its quantitation and mechanisms require much further research.

Voice and upper airway symptoms in people with chronic cough and paradoxical vocal fold movement

Chronic cough (CC) and paradoxical vocal fold movement (PVFM) share several common features; however, there has been no systematic comparison of these two conditions. The aims of this study were to contrast and compare the symptom profiles of CC and PVFM, to clarify the relationship between the two conditions, and to explore how symptom characteristics could be used to design an individualized treatment program. Participants included 55 people with a combination of PVFM and CC that was refractory to medical treatment, 8 people with PVFM alone, 56 people with CC alone, 25 people with voice disorders, and 27 normal controls. Symptoms and descriptive features of CC, PVFM, and voice disorders were assessed via structured case history interview, symptom frequency, and severity ratings, ratings of activity limitation, and anxiety/depression ratings. Results indicated consistent overlap in the symptom profile between people with CC and those presenting with a combination of CC and PVFM. Participants with PVFM without cough and those with voice disorders overlapped with the participants with CC on some dimensions; however, there were still some significant differences between them. These data suggest that CC and PVFM are related and manifestations of a common underlying condition but that voice disorders are a discrete entity. Most participants had normal ratings on screening for anxiety and depression. Results indicated that there were no consistent psychiatric symptoms in any of the groups studied, and they do not support the label of psychogenic cough for CC that is refractory to medical treatment. Characteristics of CC such as nature and timing of the cough provide important information for developing behavioral treatment programs for individual patients who have exhausted medical options. A template has been provided that is a practical method of designing an integrated behavioral treatment program based on those individual patient characteristics.