What are the treatment options for episodic throat closure?

Treatment of Episodic Throat Closure

For episodic throat closure (laryngospasm), immediate management focuses on airway patency with continuous positive airway pressure using 100% oxygen, followed by propofol (1-2 mg/kg IV) if laryngospasm persists, and suxamethonium (1 mg/kg IV) for severe cases with worsening hypoxia; long-term treatment targets the underlying cause, most commonly laryngopharyngeal reflux, with proton pump inhibitors and lifestyle modifications. 1, 2, 3

Acute Management of Laryngospasm

Immediate Interventions

• Call for help immediately and ensure the patient is in a facility capable of performing intubation or tracheostomy 1
• Apply continuous positive airway pressure with 100% oxygen using a reservoir bag and facemask while maintaining upper airway patency; avoid unnecessary airway stimulation 1
• Perform Larson's manoeuvre: place the middle finger of each hand in the "laryngospasm notch" between the posterior border of the mandible and mastoid process while displacing the mandible forward in a jaw thrust; deep pressure at this point may help relieve laryngospasm 1

Pharmacologic Escalation

• Administer propofol 1-2 mg/kg intravenously if laryngospasm persists and/or oxygen saturation is falling; while low doses may be effective in early laryngospasm, larger doses are needed in severe cases or total cord closure unresponsive to initial propofol 1
• Give suxamethonium 1 mg/kg intravenously for worsening hypoxia with continuing severe laryngospasm and total cord closure; this provides cord relaxation, permitting ventilation, re-oxygenation, and intubation if necessary 1
• Alternative routes for suxamethonium if IV access is unavailable: intramuscular (2-4 mg/kg), intralingual (2-4 mg/kg), or intra-osseous (1 mg/kg) 1
• Atropine may be required to treat bradycardia 1

Airway Monitoring

• Monitor closely for signs of impending airway closure: change in voice, loss of ability to swallow, and difficulty breathing 1
• Avoid direct visualization of the airway as trauma from the procedure can worsen angioedema or laryngospasm 1
• Consider elective intubation if the patient exhibits signs of impending airway closure; highly skilled physicians may be required due to distorted airway anatomy 1
• Ensure immediate availability of backup tracheostomy in case intubation is unsuccessful 1

Long-Term Management Based on Etiology

Laryngopharyngeal Reflux (Most Common Cause)

• Proton pump inhibitors are the primary medical treatment for laryngopharyngeal reflux, which is the most common cause of paroxysmal laryngospasm 2, 3
• Lifestyle modifications should be implemented alongside pharmacologic therapy 3
• Prognosis is generally good after treatment is initiated for reflux-induced laryngospasm 2

Paradoxical Vocal Cord Dysfunction

• Behavioral therapy is the essential treatment for episodic laryngeal dysfunction (paradoxical vocal cord dysfunction); medical intervention including hospitalization and tracheotomy must be avoided 4
• Key diagnostic feature: complete reversibility of symptoms when the patient is distracted 4
• Address gastroesophageal reflux if present, as it may be a significant contributing factor 4

Neurovascular Causes

• Microvascular decompression may be considered for episodic hemilaryngopharyngeal spasm (HELPS) syndrome when neurovascular conflict involving cranial nerves IX-X is demonstrated on MRI 5
• Botulinum toxin injections into the affected vocal cord can reduce severity of spasms but may not eliminate episodes 5

Critical Pitfalls to Avoid

• Do not use anabolic androgens or antifibrinolytic drugs for acute laryngeal attacks, as they require several days to become effective and are unreliable for acute episodes 1
• Avoid out-of-hospital use of potent narcotics such as fentanyl patches or oxycodone for symptom management 1
• Do not assume all throat closure is asthma; episodic laryngeal dysfunction can mimic asthma but is resistant to bronchodilators and anti-inflammatory drugs, with the key being complete symptom reversibility when distracted 4
• Consider alternative diagnoses including allergy, asthma, and muscle tension dysphonia, as LPR should not be the only diagnosis considered 6