Question
I recently conducted a modified barium swallow study on a patient who complained of severe coughing episodes at the beginning of her meals that subsided as she ate. During the MBS, the patient did cough forcefully with a bite of cookie. Several other item
Answer
First, it is important to understand that '...laryngeal spasm(s)...' is symptomatic of something and may have many etiologies. An irritable upper aerodigestive system has been shown to be disruptive to a patient's life (Koufman, 96, in Ballenger and Snow, Eds., Otolaryngology (15), Chap. 30, Williams and Wilkins, Phila., pp. 535-555). Acute laryngospasm is an incapacitating event with obscure etiology (Corey, et al., 99, Orolaryngol. Clinics of No. Amer., 31(1): 189-205). The Speech-Pathologist who posed this question described the signs and symptoms most likely associated with a hypersensitivity syndrome. However, it is important to have a thoroughgoing differential diagnosis before proceeding. A differential diagnosis would include ruling out Stevens-Johnson syndrome (a mucocutaneous hypersensitivity syndrome; Roujeau, et. al., 95, New Eng. Jour Med., 333(24): 1600-1608), autoimmune disorders (Campbell, et al., 83, Am. Jour. Otolaryngol., 4: 187-216) [i.e., rheumatoid arthritis (Rh factor mediated autoimmune disorder), systemic lupus erythematosis (DNA autoantibody), cicatricial pemphigoid (idiopathic epithelial autoimmunity), relapsing polychondritis (cartilaginous autoimmunity), Sjogren's syndrome (idiopathic connective tissue autoimmunity), etc.], cervical esophageal diverticulum (Zenker's), respiratory syncytial viral bronchiolitis (Khoshoo and Edell, 99, Pediatrics, 104: 1389-1390), 'irritable larynx' syndrome (Morrison, et al., 9, Jour. Voice, 13(3):447-455), eosinophilic esophagitis (Liacouras, et al., 98, Pediatrics Suppl., 104(2): 364-365), medication sensitivities (i.e., ACE-inhibitor angioedema) and tumor masses, benign or malignant (DuBuske, et al., 96, Chap. 29, in MP Fried, Ed., The Larynx, Mosby, Boston, pp. 319-333), any physiological conditions known to manifest as hyper-reactivity (i.e., paradoxical vocal fold mobility impairment; Selner, et al., 87, Jour. Allergy Clin. Immunol., 79: 726-733), and, finally, gastroesophageal and laryngopharyngeal reflux disorder (Kozarek, 90, Gastroenterol. Clin. No. Amer., 19: 713-731; Filiaci, et al., 97, Allergol. Immunopathol., 25: 266-271).
Second, if the nature of the disorder is indeed hypersensitivity, it is necessary to collect a life-time history from the patient searching for a continuity of symptoms the patient may report (Yu and Ryu, 97, Mayo Clinic Proced., 72: 957-959). Aerodigestive hypersensitivity has been shown to exist within the entire age spectrum, from the infant to the geriatric patient. Next, one would want to probe the patient carefully to discern any patterns for the occurrence of the symptoms. Evidence one would be looking for would be specific foods allergies (i.e., sulfides, aspartamine, the preservatives BHA and BHT, benzoles, tartrazine, the flavor enhancer MSG and food colorings), environmental agents [i.e., dust mites, animal danders of both pets and vermine, and molds), and inhalants (e.g., seasonal pollens, fumes and smoke, aerosolized chemicals, both industrial and household)] (Curtis and Crain, 06, Dysphagia, 2(2): 93-96) that may cause episodes of immunologic response.
Third, if a pattern were to be discerned, either for digestive or laryngeal impairment due to hypersensitivity, testing to determine the nidus of the problem is recommended. Under the management of an Otolaryngoloist (ENT), the most basic level treatment is empirical. The ENT may decide to try coughing suppressants (e.g., Theobromine) or expectorants (e.g., Guaifenesin), improving daily water intake (i.e., hydration), and/or the use of nighttime humidifiers. At the next level the ENT may start the patient on an aggressive regime for the medical management of reflux suppression, including the use of proton pump inhibitors, such as Prilosec or Prevacid, and the establishment of reflux precautions as behavioral management, antihistamines (e.g., Benadryl, Pyribenzamine, Chlor-Tremeton, etc.),or mast cell stabilizers (e.g., Cromolyn sodium). Finally, the ENT may decide to do testing of respiratory function, including the methacholine inhalation challenge, looking for signs of asthma, and imaging studies to identify anatomical abnormalities that may exist. Lastly, the ENT may decide to test the patient for allergen sensitivities with skin or blood samples for the radioallergosorbent test (Krouse and Mabry, 03, Otoalryngol. - Head and Neck Surg., Suppl., 129(4): S33-S49).
Fourth, and lastly, treatment, like most successful speech-language-pathology (SLP) intervention, is interdisciplinary. Working with the ENT, a Pulmonologist, counselors, and other necessary professionals, the SLP can launch into a regiment to establish behavioral management methods with goals to improve breathing, swallowing, and speaking impairments (Rothe and Karrer, 98, Eur. Respir. Jour., 11: 498-500). This includes continued avoidance of inciting agents (Squillance, 92, Otolaryngol. - Head and Neck Surg., Suppl., 107(6): Part 2: 831-834), management of autoimmune conditions, if required, staying with medication regimes, and developing individualized programs of diaphragmatic breathing, easy onset voice production, and mealtime management of food intake by monitoring rate and volume during the feeding cycle (Irwin, et al., 97, Arch. Intern. Med., 157: 1981-1987). The condition of laryngospasm has been given short shrift when no obvious etiology or cause appears to exist. But to the patient this is a significant impairment that reduces their quality of their life. We are thus obligated to be as thorough as is practicable when addressing this complaint.
Mr. Charpied is the Director of the Department of Speech Pathology, in the Department of Otolaryngology - Head and Neck Surgery, with the University Rochester's School of Medicine and Strong Memorial Hospital. A clinically certified Speech Pathologist who specializes in voice and swallowing, Mr. Charpied has developed techniques and manuals on the diagnosis, treatment and management of voice and swallowing disorders. He teaches at Nazareth College, as well in the ENT resident program. His research interests include anatomy of the larynx, quantification of laryngeal function through image analysis, and the use of computers as a clinical tool. Besides publications and numerous abstracts, Mr. Charpied's introductory text for speech pathology students, Introduction to the Anatomy and Physiology of the Speech Mechanism - Elements of Human Communication, will be published spring of 2007.