What are the treatment options for voice loss associated with a cough?

Voice Loss Associated with Cough: Treatment Approach

Voice loss occurring with cough requires speech and language therapy as the primary treatment, focusing on behavioral interventions that address laryngeal hypersensitivity and dysfunctional vocal patterns, while simultaneously treating the underlying cause of the cough itself. 1, 2

Understanding the Mechanism

Voice problems are extremely common in chronic cough, with over one-third of patients demonstrating strained, rough, and/or breathy voice quality to a moderate or severe degree 3. The violent forces of coughing—generating intrathoracic pressures up to 300 mm Hg and propelling air at velocities approaching 500 mph—traumatize the vocal cords, causing edema and dysfunction 4. Additionally, there is a high prevalence (81%) of neurogenic voice disorders, particularly vocal fold paresis and atrophy, in patients with chronic cough 5.

Primary Treatment Algorithm

Step 1: Make a Positive Diagnosis and Explain It

Begin by explaining that voice loss with cough represents a functional disorder where excessive laryngeal muscle tension and trauma from coughing create reversible vocal cord dysfunction—not permanent structural damage. 1, 2 This explanation itself has therapeutic value 1.

• Demonstrate the clinical signs to the patient during examination, showing them how their vocal cords can produce normal voice under certain conditions 1
• Review laryngoscopy images together to demonstrate the functional and reversible nature of the problem 2
• Emphasize that the abnormal vocal patterns are habitual responses that can be brought under voluntary control 2

Step 2: Address the Underlying Cough

Systematically evaluate and treat the cough itself, as voice symptoms often improve when cough resolves. 4

• Evaluate for upper airway cough syndrome, asthma, gastroesophageal reflux disease, and ACE inhibitor use as the most common causes 4
• If the patient is on an ACE inhibitor, discontinue it immediately—cough typically resolves within 3-7 days 4
• Mandate smoking cessation as smoking worsens both cough and laryngeal symptoms 4

Step 3: Initiate Speech and Language Therapy

Refer immediately to speech-language pathology for a structured behavioral intervention program, which has demonstrated 87% improvement rates compared to 14% with placebo. 6, 7

The speech therapy program should include four core components 6, 7:

Education Component

• Explain how excessive muscle tension in the larynx prevents normal voice production 1
• Identify and demonstrate the specific symptomatic behaviors (e.g., excessive effort in head, neck, face, shoulders) 1
• Help patients understand that even producing a hoarse whisper reflects excessive effort 1

Cough Suppression Strategies

• Teach voluntary cough suppression techniques, as simple voluntary control can reduce cough frequency 1
• Use distraction techniques such as bubble blowing into water with vocalization 1
• Employ large body movements while making sounds to redirect attention 1

Vocal Techniques to Restore Normal Function

• Facilitate natural automatic movement patterns by having patients engage in well-learned tasks like counting, reciting automatic phrases, or producing playful pre-linguistic sounds 1
• Use circumlaryngeal massage with concurrent vocalization 1
• Manually reposition and lower the larynx during phonation 1
• Have patients produce strong sounds (e.g., /ooh/) while the therapist palpates and repositions the larynx to demonstrate that normal voice is possible 1
• Employ distraction techniques that momentarily mask auditory feedback, triggering reflexive normal vocal responses 1

Vocal Hygiene Training

• Ensure adequate hydration 4
• Avoid throat clearing and excessive voice use 6
• Address environmental irritants 6

Step 4: Provide Symptomatic Relief During Treatment

While awaiting improvement from behavioral therapy:

• Use dextromethorphan 60 mg for cough suppression with fewer side effects than codeine 4
• Recommend menthol lozenges or vapor for short-term relief 4
• Suggest simple honey-lemon mixtures for symptomatic relief 1, 4

Step 5: Address Cognitive and Behavioral Factors

Incorporate cognitive-behavioral principles to challenge unhelpful thoughts that perpetuate symptoms. 1

• Help patients identify catastrophizing thoughts (e.g., "If my voice isn't perfect, I'm a failure") 1
• Plan behavioral experiments to address fear and avoidance of speaking situations 1
• For patients with long-standing anxiety, comorbid depression, or ongoing medicolegal issues, refer for formal cognitive-behavioral therapy 2

Step 6: Prepare for Setbacks and Consolidate Gains

Most patients achieve some improvement or even elimination of symptoms during the initial consultation, though this doesn't mean the disorder has fully resolved. 1

• Intensive therapy with sessions several times per week may be most successful 1
• Prepare patients for possible relapse with strategies to manage future episodes 1
• Use positive/negative practice, having patients pay attention to how the new vocal pattern feels compared to the old disordered pattern 1
• Generalize normalized behaviors into wider social contexts 1

Critical Pitfalls to Avoid

• Do not assume voice loss is purely psychological or stress-related—there are real biomechanical and neurogenic factors at play 5, 3
• Do not delay speech therapy referral—the average time between complaint of hoarseness and specific diagnosis is 32 months, which is far too long 5
• Do not prescribe opiate antitussives as they have significant adverse side effects and are not recommended 1
• Do not continue escalating medical treatments if the patient fails to respond—this suggests a functional component requiring behavioral intervention 1, 6

Expected Outcomes

Speech pathology intervention produces significant improvements in 8, 7:

• Perceptual voice quality (reduced breathiness, roughness, strain, and glottal fry)
• Maximum phonation time
• Acoustic parameters (jitter and harmonic-to-noise ratio)
• Overall cough, breathing, and upper airway symptoms