How to manage vocal cord damage after chronic coughing?

Management of Vocal Cord Damage After Chronic Coughing

The primary management strategy for vocal cord damage secondary to chronic cough is to treat the underlying cause of the cough itself, which will lead to resolution of the laryngeal dysfunction, including vocal cord edema and paradoxical vocal fold movement. 1, 2

Understanding the Mechanism of Vocal Cord Damage

The vocal cord damage from chronic coughing occurs through direct mechanical trauma rather than from the underlying disease causing the cough. 1

• Violent coughing generates intrathoracic pressures up to 300 mm Hg, propelling air past the vocal cords at velocities approaching 500 miles per hour during the expiratory phase. 1
• This extreme mechanical stress causes vocal cord edema from trauma to the laryngeal structures during their violent undulations. 1
• The resulting edema manifests as reversible, extrathoracic, variable upper airway obstruction visible on flow-volume loops. 1

Primary Treatment Approach: Address the Underlying Cough

Successful treatment of the chronic cough itself leads to improvement in all features of laryngeal dysfunction, including paradoxical vocal fold movement and extrathoracic airway hyperresponsiveness. 2

Identify and Treat the Cough Etiology

• Systematically evaluate for upper airway cough syndrome (previously postnasal drip), asthma, gastroesophageal reflux disease, and ACE inhibitor use as these are the most common causes. 3
• Obtain a chest radiograph if pneumonia is suspected based on tachypnea, abnormal lung findings, or hypoxemia. 3
• Discontinue ACE inhibitors if present, as cough resolves within 3-7 days after withdrawal. 1, 3
• For upper airway cough syndrome, use first-generation antihistamine/decongestant combinations. 3
• For asthma or bronchial hyperresponsiveness, use inhaled bronchodilators and inhaled corticosteroids. 3

Speech Pathology Intervention for Refractory Cases

When chronic cough persists despite optimal medical treatment of underlying causes, speech pathology intervention is the evidence-based next step for managing both the cough and associated laryngeal dysfunction. 4, 5

Components of Speech Pathology Treatment

The multidimensional program includes: 4

• Education about laryngeal hypersensitivity and the cough-vocal cord dysfunction relationship. 4
• Vocal hygiene training to reduce laryngeal irritation. 4
• Cough suppression strategies including therapeutic breathing maneuvers and vocal cord relaxation techniques. 6, 4
• Psychoeducational counseling to address behavioral components. 4

Evidence for Speech Pathology Effectiveness

• In a randomized controlled trial of 87 patients, speech pathology intervention produced significant reductions in cough, breathing, voice and upper airway symptoms. 4
• Treatment also improved voice quality parameters (reduced breathiness, roughness, strain, and glottal fry) and acoustic measures (maximum phonation time, jitter, harmonic-to-noise ratio). 4
• Approximately 40% of individuals with chronic cough have clinically significant voice symptoms similar to muscle tension dysphonia. 5
• The degree of improvement in cough reflex sensitivity correlates with improvement in extrathoracic airway hyperresponsiveness, demonstrating the interconnected nature of these conditions. 2

Recognition of Vocal Cord Dysfunction as Part of the Clinical Picture

Vocal cord dysfunction frequently coexists with chronic cough and should be recognized as either a cause or consequence of the cough. 1, 7

Key Clinical Features to Identify

• Throat tightness or choking sensation during coughing episodes. 7
• Inspiratory stridor that resolves within approximately 5 minutes of stopping activity. 7
• Sensation of a lump in the throat (globus sensation) as part of laryngeal hypersensitivity syndrome. 7
• Variable flattening of the inspiratory flow loop on spirometry during symptomatic periods. 7

Important Diagnostic Considerations

• Paradoxical vocal fold movement can be directly observed via fiberoptic laryngoscopy and should be assessed before and after treatment. 2
• Extrathoracic airway hyperresponsiveness to hypertonic saline provocation can be measured to quantify laryngeal dysfunction. 2
• Capsaicin cough reflex testing demonstrates sensory hyperresponsiveness in these patients. 2

Common Pitfalls to Avoid

• Do not assume vocal cord damage requires separate treatment from the cough itself - treating the underlying cough cause resolves the laryngeal dysfunction in most cases. 2
• Do not overlook vocal cord dysfunction as a potential cause of persistent cough - it should be included in the anatomic diagnostic protocol for chronic cough. 5
• Do not attribute these conditions to psychopathology - chronic cough and paradoxical vocal fold movement are not necessarily the result of underlying psychiatric disease. 5
• Do not use antibiotics, expectorants, or bronchodilators for nonproductive cough without a specific indication, as they are ineffective. 8

Symptomatic Management During Treatment

While addressing the underlying cause: 8

• Dextromethorphan (60 mg for maximum effect) provides cough suppression with fewer side effects than codeine. 8
• Menthol lozenges or vapor offer short-term relief through cold and menthol-sensitive receptors. 8
• Adequate hydration and simple honey-lemon mixtures can provide symptomatic relief. 8
• Smoking cessation is mandatory as smoking worsens both cough and laryngeal symptoms. 1, 8