What is the appropriate evaluation and management for a patient with audible throat clicks and intermittent laryngeal spasms?

Evaluation and Management of Throat Clicks and Laryngeal Spasms

Perform diagnostic laryngoscopy promptly to visualize the larynx and vocal cords, as this is the primary diagnostic modality for evaluating throat symptoms and can identify serious underlying pathology including vocal cord dysfunction, laryngeal spasms, structural abnormalities, or malignancy. 1

Initial Clinical Assessment

Key Historical Features to Elicit

• Duration and pattern of symptoms: Intermittent versus constant clicking sounds, frequency and triggers of throat spasms 1
• Associated respiratory symptoms: Inspiratory stridor, throat tightness, dyspnea that peaks during exercise and resolves within 5 minutes suggests vocal cord dysfunction rather than structural pathology 2
• Response to bronchodilators: Wheezing or throat symptoms that fail to respond to beta-2 agonists or inhaled corticosteroids is a critical red flag for vocal cord dysfunction 2
• Recent surgical history: Any head, neck, or chest surgery, or recent endotracheal intubation increases risk of vocal fold paralysis or injury 1
• Tobacco use: Smoking significantly increases risk of polypoid vocal fold lesions and laryngeal cancer, warranting expedited evaluation 1
• Professional voice use: Teachers, singers, and others who rely on voice for livelihood require early evaluation due to psychological and economic ramifications of delayed diagnosis 1, 3

Physical Examination Priorities

• Assess for respiratory distress or stridor: These findings mandate immediate escalated care 1
• Palpate for concomitant neck mass: This requires expedited laryngeal evaluation 1
• Evaluate cranial nerve function: Neurologic deficits may indicate neurogenic causes of vocal dysfunction 1

Diagnostic Approach

Laryngoscopy as Primary Diagnostic Tool

Clinicians should perform diagnostic laryngoscopy without delay for patients with throat clicks and spasms, as visualization of the larynx is essential to establish a diagnosis and avoid misdiagnosis or delayed diagnosis of serious conditions. 1

• Laryngoscopy can be performed at any time based on clinical presentation and is safe with minimal risk 1
• Most throat symptoms are caused by pathology identifiable by laryngoscopy, making it more valuable than imaging studies 1
• Flexible nasolaryngoscopy can be effectively performed in primary care settings with 89% success rate on first attempt and 71% of patients managed without specialist referral 4

Specific Findings to Assess During Laryngoscopy

• Vocal cord movement abnormalities: Paradoxical vocal cord motion during inspiration suggests vocal cord dysfunction 2
• Structural lesions: Polyps, nodules, cysts, masses concerning for malignancy 1, 4
• Vocal fold paralysis or paresis: Unilateral immobility requires imaging from skull base to thoracic inlet to evaluate the entire recurrent laryngeal nerve pathway 1
• Signs of laryngopharyngeal reflux: Posterior laryngeal edema, erythema, though these findings have poor specificity 1
• Laryngeal trauma or intubation injury: Particularly relevant in post-surgical patients 1

Pulmonary Function Testing

• Spirometry with flow-volume loops should be obtained if vocal cord dysfunction is suspected clinically 2
• Variable flattening of the inspiratory flow loop during symptomatic periods is the key diagnostic finding, contrasting with expiratory flow limitation in asthma 2
• Normal spirometry between episodes does not exclude vocal cord dysfunction 2

When Imaging Is Indicated

Do NOT obtain CT or MRI prior to visualizing the larynx, as imaging is unnecessary in most patients and should only be used to assess specific pathology identified on laryngoscopy. 1

• If laryngoscopy reveals unexplained vocal fold paralysis, obtain imaging from skull base to thoracic inlet/aortic arch to evaluate the entire recurrent laryngeal nerve course 1
• MRI with gadolinium is preferred for skull base and brain stem lesions, particularly if additional lower cranial nerve palsies are present 1
• CT is appropriate for evaluating laryngeal, pharyngeal, and thyroid lesions, though radiation exposure to the thyroid should be considered 1

Management Based on Diagnosis

Vocal Cord Dysfunction (Paradoxical Vocal Fold Motion)

If laryngoscopy confirms paradoxical vocal cord movement, refer for speech therapy with breathing retraining and vocal cord relaxation techniques as the primary treatment. 2

• Provide clear patient education that abnormal vocal cord movements are reversible habitual patterns, not irreversible structural damage 2
• Review laryngoscopy images with the patient to demonstrate the functional nature of the disorder 2
• Speech therapy techniques include:
  • Natural reflexive behaviors and playful sounds (sighing "ah," quiet sirens, low-pitched glottal fry, giggling) 3, 2
  • Automatic phrases with minimal communicative responsibility (counting, days of the week, singing familiar songs) 3, 2
  • Circumlaryngeal massage with concurrent vocalization 3, 2
  • Attentional redirection techniques like bubble blowing into water with vocalization 2
• Consider cognitive-behavioral therapy referral for long-standing anxiety, comorbid depression, or ongoing medicolegal issues 2

Laryngospasm Management

If acute laryngospasm occurs during evaluation:

1. Apply continuous positive airway pressure with 100% oxygen using reservoir bag and facemask while ensuring upper airway patency 1
2. Avoid unnecessary upper airway stimulation 1
3. Larson's maneuver: Apply deep pressure in the "laryngospasm notch" between posterior mandible and mastoid process while displacing mandible forward 1
4. If persistent with falling oxygen saturation: Propofol 1-2 mg/kg IV (larger doses needed for severe laryngospasm) 1
5. If worsening hypoxia continues: Suxamethonium 1 mg/kg IV to provide cord relaxation 1

Benign Vocal Fold Lesions or Muscle Tension Dysphonia

If laryngoscopy identifies benign lesions or muscle tension patterns, advocate for voice therapy as there is moderate-to-good evidence supporting direct symptomatic and behavioral therapies. 1, 3

• Voice therapy should not begin until laryngoscopy establishes a diagnosis, as failure to visualize the larynx can lead to inappropriate therapy or delayed diagnosis 1
• Document and communicate laryngoscopy findings to the speech-language pathologist prior to initiating therapy 1
• Voice therapy is particularly effective for patients with voice-related quality of life impairment 1, 3

What NOT to Do

• Do not prescribe antibiotics for presumed viral laryngitis causing throat symptoms—they show zero effectiveness and contribute to antibiotic resistance 3
• Do not prescribe systemic corticosteroids without laryngoscopy—there is no evidence for efficacy and they carry significant risks including masking serious pathology 3
• Do not prescribe proton pump inhibitors empirically without laryngoscopy—there is no evidence supporting empirical PPI use for throat symptoms alone 3
• Do not misdiagnose vocal cord dysfunction as refractory asthma and escalate asthma therapy unnecessarily—look for inspiratory symptoms and lack of bronchodilator response 2

Common Pitfalls and How to Avoid Them

• Assuming all throat clicks/spasms are benign: Throat symptoms can be the presenting sign of laryngeal cancer, vocal fold paralysis from recurrent laryngeal nerve compression by mediastinal masses, or neurologic disease 1
• Delaying laryngoscopy in smokers: Tobacco users with throat symptoms require particular concern due to increased risk of malignancy and warrant expedited evaluation 1
• Relying on spirometry alone: Vocal cord dysfunction may show normal flow-volume loops when asymptomatic, so timing of testing during symptomatic periods is critical 2
• Confusing vocal cord dysfunction with asthma: Key distinguishing features are inspiratory stridor (not expiratory wheeze), throat tightness, rapid resolution with rest, and failure to respond to bronchodilators 2