Seeing the Forest Through the Wheeze: Laryngeal Involvement in ...

Seeing the Forest Through 

the Wheeze: 

Laryngeal Involvement in 

Episodes of Dyspnea 

Marc Haxer, M.A., CCC-Sp 

Departments of Speech-Language Pathology 

and Otolaryngology/Head and Neck Surgery 

University of Michigan Health System

Introduction 

• Goals/Objectives 

– Become familiar with upper versus lower 

airway etiologies for dyspnea 

– Become able to differentially diagnose upper 

airway involvement in dyspnea 

– Become familiar with chronic cough, 

involuntary vocal fold closure, laryngospasm, 

adductory laryngeal breathing dystonia and 

irritable larynx syndrome as they relate to 

compromised respiration

Larynx 

• Cartilaginous tube 

– Connects inferiorly to respiratory system 

• Trachea, lungs 

– Connects superiorly to vocal tract 

• Pharynx, oropharynx, nasopharynx 

• Anatomic orientation important 

– Highlights interactive relationship between vocal 

subsystems 

• Pulmonary mechanism 

• Laryngeal valve 

• Supraglottic vocal tract resonator

Larynx 

• Complex arrangement of muscles, mucus 

membranes, and other connective tissue 

– Soft tissues responsible for airway preservation 

– Cartilage housing serves as columnar protective shield 

for laryngeal valve 

• Muscles and cartilages provide three levels of 

“folds” 

– Serve as sphincters which provide communicative and 

vegetative functions 

– Angles of closure multidimensional (valve in 

horizontal and vertical planes)

Larynx 

• Upper rim of larynx formed by 

aryepiglottic folds 

– Fibrous membrane extending from epiglottis 

to arytenoid towers 

– Thus serves as lateral boundary of larynx 

– Epiglottic inversion posteriorly/inferiorly over 

laryngeal vestibule results in separation of 

larynx from pharynx and serves as most 

superior level of airway protection

Larynx 

• Second sphincter formed by ventricular folds 

– Not normally active during phonation 

– Can become hyperfunctional during episodes of 

increased vocal effort/extreme vegetative closure 

– Directly superior to ventricle/true vocal folds 

– Form double layer of medial closure w/TVFs if needed 

– Principle function is to increase intrathoracic pressure 

by blocking exhalatory airflow from lungs 

– Compress tightly during sneezing/coughing, lifting, 

emesis, childbirth, defecation 

– Also provide medial level of airway protection during 

swallows

Larynx 

• Most inferiorly are true vocal folds 

– Provide vibrating source for phonation 

– Also close tightly for nonspeech and vegetative tasks 

• Thus, larynx and vocal folds function as variable 

valve 

– Modulate airflow through VFs during phonation 

– Close off trachea/lungs to prevent soiling of airway 

during swallows 

– Provide resistance to increased abdominal pressure 

during effortful activities

Neurologic Supply 

• Cranial nerve X innervates larynx 

peripherally 

– Vagus = “wanderer” 

– Innervates sites from skull to abdomen 

• Innervates larynx through two important 

branches 

– Superior laryngeal nerve (SLN) 

– Recurrent laryngeal nerve (RLN)


• Superior laryngeal nerve 

– Branches off vagus near nodose ganglia in 

neck 

– Course alongside carotid artery 

– Forms internal/external branches 

• Internal branch inserts through thyrohyoid 

membrane superior to VFs and provides all sensory 

information to larynx 

• External branch is motor nerve to cricothyroid (CT) 

muscle


• Recurrent laryngeal nerve 

– Extends to thorax 

– Forms long loop under heart before coursing 

superiorly under thyroid gland and into larynx 

– Different on right/left sides of body 

• L RLN courses under aorta 

• R RLN course under subclavian artery 

– Nerves (especially left) susceptible to injury 

– Supplies all sensory information to area below VFs 

and all motor innervation to PCA, TA, LCA, and IA 

muscles

Larynx

Where/What’s the Problem? 

• Upper airway issue? 

• Lower airway issue? 

• Problem w/inhalation? 

• Problem w/exhalation? 

• Problem w/both? 

• Acute versus chronic issue? 

• Episodes same/different w/regard to 

presentation? 

• Episodes same/different w/regard to severity?

Upper Airway Issues that can 

Compromise Respiration 

• Unilateral vocal fold motion impairment (abductory) 

• Bilateral vocal fold motion impairment (abductory) 

• Reinke’s edema 

• Laryngeal papilloma 

• Laryngeal carcinoma 

• Vocal Fold Granuloma 

• Laryngospasm 

• Involuntary vocal fold closure 

• Cough 

• Adductory Laryngeal Breathing Dystonia 

• Acute infection (eg croup, laryngitis, epiglottitis) 

• Allergies 

• Laryngomalacia 

• Tracheomalacia/Stenosis 

• Foreign body in airway 

• Extrinsic/intrinsic airway compression by tumor inferior to glottis

Unilateral Vocal Fold Paralysis

Bilateral Vocal Fold Paralysis

Reinke’s Edema

Laryngeal Papilloma

Laryngeal Carcinoma

Vocal Fold Granuloma

Laryngitis

Laryngomalacia

Tracheal Stenosis

Lower Airway Issues that can 

• Asthma 

• COPD 

• Emphysema 

Compromise Respiration 

• Restrictive Airway Disease 

• Lung Cancer 

• Interstitial lung disease

Chronic Illnesses/Disorders That 

Can Affect Laryngeal Function 

• Chronic sinusitis/URI 

– Cough/throat clear 

• Can cause trauma to laryngeal tissues 

– Antihistamines 

• Dry secretions 

• Resultant dehydration of VFs 

– Anti-cough medications 

• Drying agents 

• Contribute to VF dehydration



• Asthma 

• Chronic obstructive pulmonary disease 

• Emphysema 

• Lung CA 

– Above can be direct/indirect cause of laryngeal 

problems 

• Vocal fold tissue abuse 

• Poor breath support 

• Vocal fold dryness secondary to medication use 

• VF paresis/paralysis 

• Cough



• Allergies 

– Congestion/edema of VFs 

– VF dehydration 

– VF tissue trauma 

• cough/throat clear



• Laryngopharyngeal reflux disease 

– Is GERD that affects pharynx/larynx 

– Occult chronic reflux is etiologic factor in high 

percentage of patients w/laryngologic complaints 

– Reflux involves multiple anatomic sites 

• LES 

• Entire esophagus 

• UES 

• Larynx/pharynx/oral cavity 

• Trachea 

• Lungs




– Symptoms 

• Chronic hoarseness 

• Voice fatigue 

• Cough 

• Chronic throat clearing 

• Globus sensation 

• Sensation of choking 

• Edema 

• Ulceration/granulation of laryngeal mucosa 

• Hyperkeratosis 

• Carcinoma of larynx




– LPRD best managed via multidisciplinary team 

• Otolaryngologist 

• Internist/PCP 

• Gastroenterologist 

• Allergist 

• Pulmonologist 

• Speech Pathologist 

• Nutritionist




– Almost always associated w/some degree of 

aspiration 

• Amount of aspiration may be clinically insignificant 

• Or, may be clinically significant enough to cause: 

– Chronic cough 

– Involuntary vocal fold closure 

– Reactive airway disease 

– Difficult to control asthma 

– Pneumonia 

– Bronchiectasis




– Evaluation 

• Esophagram 

• Dual 24-hour pH probe 

• Bravo capsule study 

• Flexible fiberoptic endoscopy




– Treatment 

• Behavioral 

• Chewable antacids 

• Viscous antacids 

• H2-receptor antagonists 

• Proton pump inhibitors 

• Nissen fundoplication/Stretta procedure



• Smoking/alcohol abuse/illicit drug use 

– Erythema/edema 

– Generalized inflammation 

– Drying of mucous membranes 

– Incoordination/dysarthria/impaired judgment 

– LPRD 

– Chronic cough

Primary Disorder Etiologies That 


• Environmental stress 

– Loss of employment 

– Death of spouse/significant other 

– Family conflict 

• Conversion behaviors 

– Avoidance behavior(s) developed to counteract stressful 

situation(s) 

– Whispering, muteness, unusual dysphonias 

• Identity conflict 

– Establishment of own personality 

• High-pitched falsetto in post-pubescent adolescent 

• Weak, juvenile, thin-sounding voice of adult female 

• Raised pitch in male-to-female transsexual

Case Study #1 

• 41 year-old female 

• Presenting Dx of “difficult to control asthma” 

• Trialed on multiple courses of different asthma 

medications over a # of months w/no appreciable 

improvement in respiratory function 

• No hx of smoking/excessive alcohol use 

• Presenting symptoms 

– Chronic sense of chest tightness 

– Chronic restriction of inhalation/exhalation 

– Sense of “elephant sitting on chest” 

– Chronic hoarseness X12 months w/no Otolaryngologic 

examination 

– Denied sense of throat constriction

Case Study #1 

• Presenting symptoms not consistent with 

upper airway involvement 

• Extended duration of hoarseness 

concerning 

• Referral to Otolaryngology 

• Fiberoptic endoscopic exam results 

– Marked endolaryngeal erythema/edema 

– Laryngeal candidiasis 

– No concerning lesions

• Treatment 

Case Study #1 

– Speech Pathology not involved in Tx 

– Aggressive pharmacologic management of 

LPRD/candidiasis for six months 

• Oral anti-fungal medication (swish/swallow) 

• Anti-reflux management 

– Rigid behavioral strategies 

– 40mg PPI b.i.d. 30 minutes prior to oral intake

• Results of treatment 

– 40 lb. weight loss 

Case Study #1 

– Return of baseline vocal functioning 

– Return of baseline respiratory functioning 

– Secondary to tx, QOL markedly improved

Irritable Larynx Syndrome 

Chronic Throat 

Clearing 

Chronic Cough 

IVFC 

Laryngospasm


• Postulated by Morrison, Rammage, and 

Emami in 1999 

• Suggests that various laryngeal behaviors 

can be categorized within the context of 

“hyperkinetic laryngeal dysfunction”

These Behaviors Include: 

• Muscle Tension Dysphonia 

• Episodic laryngospasm 

• Globus sensation 

• Cough

Muscle Tension Dysphonia 

• Incoordination between respiration and 

phonation 

• Above results in elevated levels of 

laryngeal/throat muscle tension 

• In turn, contributes to general laryngeal 

hyperfunction 

– Laryngeal pain/discomfort 

– Increased vocal effort 

– Vocal fatigue

Muscle Tension Dysphonia 

• In addition to elevated levels of tension in 

larynx/throat, can also contribute to 

increased tension in neck, shoulder, and 

upper chest musculature 

– Can then masquerade as sensation of limited 

movement of air through the neck/throat area 

during inhalation

Episodic Laryngospasm 

• Adduction of VFs during inhalatory phase of respiration 

• In differential Dx 

– Involuntary Vocal Fold Closure 

– Adductory Laryngeal Breathing Dystonia 

– Closure of VFs as protective mechanism during reflux episode 

• Somatoform/anxiety disorder? 

– Intrinsic/extrinsic stress vs. psychological issue 

– Larynx “Achilles heel” for stress/anxiety? 

• Variations on a theme? 

– Asthma variant 

• Functional? 

– Implies normal structure/function of larynx but inappropriate behavior 

of the same

Globus 

• “Lump in throat” sensation 

• Secondary to increased levels of muscle 

tension in larynx? 

– Inappropriate resting or holding position of 

laryngeal musculature 

• Secondary to laryngopharyngeal reflux 

disease? 

– Laryngeal erythema/edema masquerading as 

sensation of mucous

Cough 

• Secondary to respiratory disease? 

– Acute vs. chronic 

– Productive vs. non-productive 

• Secondary to laryngopharyngeal reflux disease? 

• Increase in stress/anxiety? 

– Stress vs. psychogenic 

– Functional? 

• Secondary to allergies? 

• Neuropathic?

For All of These Behaviors 

• Larynx appears structurally normal on 

visualization 

• Abnormal laryngeal muscle posture 

present 

– Anteroposterior “squeeze” of laryngeal 

complex 

• Palpable laryngeal muscle tension present 

– Massage of thyroid cartilage/hyoid bone 

results in pain, discomfort


• Defined as: 

– “hyperkinetic laryngeal dysfunction resulting 

from an assorted collection of causes in 

response to a definitive triggering stimulus”

ILS – Inclusion Criteria 

• Symptoms attributable to laryngeal tension 

– Dysphonia and/or laryngospasm 

• With or without chronic cough 

• Visible and palpable evidence of tension 

– Lateral and A/P compression of larynx during 

laryngoscopic examination 

– Discomfort during laryngeal palpation 

• Presence of sensory trigger(s) 

– Airborne substance 

– Esophageal irritant 

– Odors

ILS – Exclusion Criteria 

• Apparent organic laryngeal pathology 

• Identifiable neurologic disease 

• Identifiable psychiatric diagnosis

Patients with Dx of ILS 

• Tend to have complex combination of signs, 

symptoms, and background factors 

• Laryngospasm and dysphonia are two major ILS 

symptoms 

– Laryngospasm most distressing to patient 

• More minor symptoms 

– Globus 

– Cough 

– Perilaryngeal pain 

• Above will vary from patient to patient

ILS Symptom Complex Grouping 

• Laryngospasm alone 

• Laryngospasm with dysphonia, globus, or 

cough 

• Dysphonia alone 

• Dysphonia with laryngospasm, globus, or 

cough 

• Other 

– Globus and/or cough

• Airborne irritants 

• Reflux 

Triggering Stimuli 

• Perfumes/colognes 

• Foods 

• Emotions 

• Voice use 

• Exertion

• Reflux 

• Viral 

Possible Etiologic Factors 

• Stress/Psychogenic 

• Asthma 

• Environmental allergy(ies) 

• Torsion injury to neck/throat/larynx

Hypothesis for ILS 

• Develops as reaction to some sort of CNS change that 

leaves sensorimotor pathways in state of hypersensitivity 

• # of possible causative factors 

• Several can be active in any one patient 

• Most prevalent 

– Emotional distress 

• Stress component vs. psychogenic cause 

– Habitual inappropriate resting posture of laryngeal musculature 

– LPRD 

– Post-viral illness 

• Viral neuropathy

Treatment 

• Reflux management 

– Behavioral/pharmacologic 

• Exercises 

• Stress management 

• Massage/manipulation 

• Non-reflux pharmacologic management 

– Botulinum Toxin A 

– Nebulized topical anesthetic 

– Amitriptyline/Gabepentin

Cough 

• Important respiratory defense mechanism 

• Responsible for clearance of excessive 

secretions, fluids, or foreign materials 

from the airway 

• Despite this protective role, excessive 

coughing can result in multisystem issues 

– Anxiety, dysphonia, fatigue, urinary 

incontinence, emesis, rib fracture(s), etc.

Cough – Differential Diagnosis 

• Upper Respiratory 

Tract 

• Allergic or vasomotor 

rhinitis, postnasal drip 

syndrome, 

infectious/postinfectious 

cough, 

sinusitis


• Lower Respiratory Tract • Abscess, allergic 

inflammation, aspiration, 

asthma, bronchiectasis, 

bronchitis, COPD, cystic 

fibrosis, drugs, 

eosinophilic bronchitis, 

interstitial lung disease, 

pertussis, primary or 

metastatic lung tumors, 

sarcoidosis, tuberculosis


• Cardiovascular system 

• Gastrointestinal 

system 

• Left ventricular 

failure, mitral 

stenosis, medications 

(ACE inhibitors) 

• Reflux disease 

(laryngopharyngeal)


• Central Nervous 

System (psychological 

response) 

• D’Urzo and Jugovic (2002) 

• Habit cough, chronic 

cough, psychogenic 

cough, neuropathic 

cough

Cough – Clinical Presentation 

• School age children to older adults 

• Average length of cough months to years 

• Most pts have attempted multiple 

interventions w/o resolving of cough 

• Most have associated fatigue 

• Most do not have accompanying 

hoarseness 

• Most have been treated for reflux for a 

short period of time w/o success

Cough 

• Habit/chronic cough 

– Larynx engaged in disordered loop of behavior 

• Psychogenic cough 

– Cough occurs secondary to emotional/psychological issues 

• Laryngeal hypersensitivity/hyper-reactivity 

– Larynx over-reacts to triggering stimuli secondary to irritation of 

the larynx by refluxed stomach contents 

• Neuropathic cough 

– Cough occurs secondary to viral neuropathy 

• Cough Hypersensitivity Syndrome (Morice, 2009) 

– Th2-type immune response vs. reflux symptoms

Behavioral/Environmental History 

• Nature of cough 

– Light dry coughs throughout the day 

– Severe/overwhelming cough “attacks” 

• Pattern of cough 

– Occurs at specific time(s) of day? 

– Follow meals or specific activity(ies)? 

– Getting worse/remaining stable? 

• Work/home/social environment 

– New building materials? 

– Ventilation relative to work space? 

– Dusty and/or dry environment?

Cough - Tx 

• Habit/chronic cough 

– Behaviorally reposture larynx into appropriate pattern of functioning 

– Improve laryngeal environment 

– Improve awareness of sensations/behaviors that precipitate cough 

– Implement behavior to delay/eliminate the cough before it 

“recalibrates” laryngeal sensitivity threshold 

• Psychogenic cough 

– Behavioral/psychological treatment 


– Behavioral/aggressive reflux tx 

• Neuropathic cough 

– Amitriptyline, Gabepentin 

• Cough Hypersensitivity Syndrome 

– Treat causal phenotype appropriately

Involuntary Vocal Fold Closure 

• Confusing disorder that is frequently 

mistaken for asthma or organic 

obstructive upper airway conditions 

• Fully 78 different names for disorder in 

the literature 

• Encompasses inappropriate vocal fold 

adduction during inhalation

• Sudden onset 

IVFC - Symptoms 

• Compromised inhalation 

• Sensation of throat closure/tightness 

• Inhalatory stridor

• IVFC 

IVFC Mimicking Asthma 

– Throat tightness, 

dysphonia during 

episodes – esp 

inhalation 

– Little/no improvement 

w/use of 

bronchodilators during 

episodes 

– No night awakening or 

cough unless 

associated with refluxinduced 

laryngospasm 

• Asthma 

– Chest tightness – esp 

exhalation 

– Improvement w/use of 

bronchodilators 

– Nighttime symptoms 

frequent

IVFC Mimicking Asthma 

– Symptoms early in exercise 

– Recovery period 5-10 

minutes 

– Turbulence at level of 

larynx, +/- stridor 

– Pt able to pant/breath hold 

during episode – may 

improve symptoms 

– PFTs characterized by 

truncated inspiratory loop 

w/normal exhalatory loop 

w/no bronchodilator 

response 

– Normal lung volumes 

– Female preponderance 

– Symptoms later in exercise 

– Recovery period 15-60 

minutes 

– Turbulence in lungs 

w/wheeze, no stridor 

– Pt unable to pant/breath 

hold when symptomatic 

– PFTs abnormal (airflow 

obstruction) 

w/bronchodilator response 

– Increased residual lung 

volume 

– Males/females equally 

affected

• Causal factors 

IVFC 

– Functional or psychogenic issue? 

– Laryngeal hypersensitivity/hyper-reactivity? 

– Laryngospasm? 

– Adductor laryngeal breathing dystonia (Blitzer and 

Brin, 1991; Grillone, et.al., 1994) 

• Rare disorder whose symptoms are similar to IVFC 

• Neurological issue 

• Behavioral intervention not efficacious in management

IVFC - Evaluation 

• History 

– Acute versus chronic issue? 

– Episodes same/different w/regard to 

presentation? 

– Episodes same/different w/regard to severity? 

– Triggers 

• Flexible endoscopy during/subsequent to 

challenge 

• Spirometry

IVFC - Treatment 

• Functional issue 

– Behavioral intervention 

• Psychogenic issue 

– Behavioral/psychological treatment 


– Aggressive reflux management 

• Laryngospasm 

– Aggressive reflux management, behavioral management, use of 

Heliox if severe, tracheotomy if life-threatening 

• Adductory laryngeal breathing disorder 

– Botulinum Toxin A injections

Case Study #2 

• 13 year-old female 

• Placed into foster care/living w/supportive 

foster mother 

• Reason for placement – ongoing 

sexual/psychological abuse at hands of 

one parent w/other parent/family 

members unable/unwilling to intervene 

• Patient actively pursuing legal severance 

of parental rights/involvement w/family

Case Study #2 

• Parents/other family members under court 

order not to contact patient 

• When court order violated, patient 

experienced episodes of dyspnea: sudden 

onset, sensation of throat constriction, 

compromised inhalation, and inhalatory 

stridor

Case Study #2 

• During flexible endoscopy, sudden onset of VF 

adduction occurred 

• Use of behavioral intervention efficacious in 

alleviating episode 

• Episodes continued to occur but were effectively 

managed w/behavioral strategies 

• Episodes ceased subsequent to legal severance 

of parental/family rights, adoption of patient by 

foster mother, and 18 months of psychotherapy

Thank you!

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