What is the recommended management for laryngeal hypersensitivity secondary to costochondritis?

Management of Laryngeal Hypersensitivity Secondary to Costochondritis

The primary treatment approach should focus on managing the costochondritis itself with NSAIDs and local corticosteroid injections, while simultaneously addressing laryngeal hypersensitivity through speech and language therapy, as the laryngeal symptoms are likely a secondary manifestation of the underlying chest wall inflammation and pain. 1, 2

Understanding the Clinical Connection

The relationship between costochondritis and laryngeal hypersensitivity represents a complex interplay where:

• Costochondritis causes severe coughing and chest pain, which can trigger or perpetuate laryngeal hypersensitivity through repeated mechanical irritation and sensory hyperresponsiveness 3, 4, 5
• Laryngeal hypersensitivity syndrome manifests as chronic cough, vocal cord dysfunction, and globus sensation, all of which can be exacerbated by the underlying chest wall inflammation 1
• The cough itself becomes a self-perpetuating cycle, where costochondritis triggers cough, which worsens laryngeal sensitivity, which triggers more cough 4, 5

Primary Management: Treat the Costochondritis

First-Line Therapy

• NSAIDs are the cornerstone of costochondritis treatment and should be initiated immediately to reduce chest wall inflammation 3, 2
• Local corticosteroid injections into the affected costochondral junctions provide rapid symptomatic relief, with all patients in one study reporting improvement 2
• Early diagnosis and treatment significantly reduce hospital admissions and investigations (39 admissions pre-treatment vs 6 post-treatment, p < 0.0001) 2

For Recurrent or Refractory Cases

• Sulfasalazine should be considered for recurrent costochondritis, with 10 of 11 patients responding in published series 2
• Adequate debridement is essential only for infectious costochondritis (rare), which presents with purulent drainage and requires surgical intervention 3, 6

Secondary Management: Address Laryngeal Hypersensitivity

Speech and Language Therapy (Primary Intervention)

Speech and language therapy is the definitive treatment for laryngeal hypersensitivity syndrome and should be initiated after respiratory assessment confirms the diagnosis. 1

The therapy approach includes:

• Assessment to help patients understand their disorder, recognize key triggers that stimulate the urge to cough, and identify how they respond behaviorally to those triggers 1
• Behavioral modification techniques to interrupt the cough-hypersensitivity cycle 1
• Laryngeal recalibration therapy may be beneficial, with 85% of patients experiencing symptom response 7

Diagnostic Pathway Before Therapy Referral

• Referral should follow respiratory assessment by a physician, which should usually include spirometry 1
• Laryngoscopy should be performed to document laryngeal findings and exclude alternative diagnoses, though findings alone have <50% sensitivity and specificity 7
• The diagnosis should be clearly established prior to referral for speech therapy, though self-referred patients should be encouraged to seek formal respiratory assessment 1

Pharmacologic Adjuncts for Laryngeal Symptoms

If gastroesophageal reflux is suspected as a contributing factor:

• Consider a trial of PPI therapy, but do not continue beyond 3 months without objective response 8, 7
• Laryngoscopy is recommended before prescribing antireflux medication for isolated laryngeal symptoms 7
• After one failed 3-month trial of appropriate PPI therapy, consider laryngeal hypersensitivity as the primary diagnosis rather than refractory reflux 7

For persistent symptoms despite behavioral therapy:

• Neuromodulators like gabapentin may reduce symptoms contributed by laryngeal hypersensitivity and hypervigilance 7
• Antidepressants may be considered based on evidence of benefit in overlapping disorders, though no RCTs exist specifically for functional dysphagia 1

Critical Pitfalls to Avoid

• Do not mistake laryngeal hypersensitivity for asthma – failure to respond to beta-2 agonists and inhaled corticosteroids is a key distinguishing feature 9
• Do not delay treatment of costochondritis – the mean time to diagnosis in one series was 9.4 months, during which patients underwent unnecessary cardiac workups 2
• Do not use oral corticosteroids routinely for hoarseness or laryngeal symptoms, as they show adverse events without proven benefit 1
• Recognize that psychiatric comorbidity is often secondary rather than causal in laryngeal hypersensitivity syndrome 1
• Laryngeal hypersensitivity can occur without meeting DSM-5 criteria for somatic symptom disorder 1

Treatment Algorithm

1. Confirm costochondritis diagnosis through physical examination (reproducible chest wall tenderness) 2
2. Initiate NSAID therapy and consider local corticosteroid injections for immediate symptom relief 2
3. Perform respiratory assessment with spirometry to evaluate for laryngeal dysfunction 1
4. Consider laryngoscopy if laryngeal symptoms are prominent, but recognize its limitations 7
5. Refer to speech and language therapy for behavioral management of laryngeal hypersensitivity 1
6. For recurrent costochondritis, add sulfasalazine 2
7. For persistent laryngeal symptoms despite behavioral therapy, consider neuromodulators 7