CHRONIC COUGH is a cough that may persist from three weeks to several years. The five most common causes of chronic cough, according to the National Lung Health Education Program, include chronic bronchitis due to smoking, postnasal drip, post-infection (both viral and bacterial), GERD/LPR, asthma, and angiotensin converting enzyme inhibitors. Quoting the NLHEP website, www.nlhep.org: “Cough is an important defense mechanism that plays a major role in maintaining the integrity of the airways and can be voluntary or involuntary. The pathophysiology of cough is incompletely understood. Cough is commonly triggered by mechanical or chemical stimulation of receptors in the pharynx, larynx, trachea and bronchi. Cough receptors also exist in the nose, paranasal sinuses, external auditory ear canals, tympanic membranes, parietal pleura, esophagus, stomach, pericardium and diaphragm.”
HOARSENESS is a harsh, rough quality to the voice. It is generally caused by irritation or injury to the vocal cords, also called vocal folds. This is most frequently caused by a viral infection, less frequently by a bacterial infection, and many times from overuse of the voice. Examples include yelling, screaming and loud singing. Inhaled irritants such as smoke can also cause hoarseness. Other causes include chronic sinusitis, laryngopharyngeal reflux and, less frequently, tuberculosis, syphilis and cancer.
LARYNGITIS is an inflammation of your voice box or “larynx” due to overuse, irritation or infection. Laryngitis may be short-lived or “acute” or long-lasting or “chronic.” Although acute laryngitis usually is nothing more than an irritation and inflammation from a virus, persistent hoarseness can signal a more serious problem. If you are persistently hoarse for more than two weeks, you need to see your physician.
The REFLUX FINDING SCORE (Belafsky, Postma & Koufman, 2001) is an eight-item assessment tool designed to help clinicians reliably diagnose, evaluate clinical improvement and assess therapeutic efficacy of patients with LPR. The RFS normative data suggests that subtle findings of LPR are present in most individuals. Statistically however, the RFS provides 95 percent certainty that an individual with an RFS greater than seven has LPR.
The REFLUX SYMPTOM INDEX (Belafsky, Postma & Koufman, 2002) is a nine-item index designed to help patients rate the severity of reflux symptoms that are specific to LPR. Normative data suggests that a RSI greater than or equal to 10 is clinically significant. Therefore, a RSI > 10 may be indicative of significant reflux disease.
VCD (aka Paradoxical Vocal Cord Motion, aka Laryngeal dyskinesia) can be characterized as an abnormal closure of the vocal cords during the respiratory cycle, particularly during the inspiratory phase, that produces airflow obstruction. It frequently mimics asthma, but is considered a behavioral phenomenon, and usually can be treated easily with breathing exercises. Some of the triggers for the “attacks” may include physiological events as well as psychological events; i.e. anxiety. A thorough evaluation is required to effectively treat this disorder, but most individuals recover very quickly once intervention begins.
Videostroboscopy of the Larynx
Videostroboscopy is a clinical evaluation tool, which allows one to directly observe the apparent motion of the larynx. This examination provides valuable information beyond that which the naked eye can see. It gives the clinician information regarding vocal fold vibration as well as an immediate and magnified image of the presence or absence of pathology. It can also document small changes in the vibratory capacity of the larynx as a result of a specific treatment modality. The presence of abnormal vibration may be detected using videostroboscopy long before the actual pathology becomes visually detectable to the naked eye. Videostroboscopy also provides a permanent record for documentation and comparison. Videostroboscopy has been found to be a valuable means for evaluating the degree of infiltration by cancerous lesions. Stroboscopy is also a very useful way to evaluate patients with vocal fold paralysis, because the onset of any improvement can often be observed earlier and with greater accuracy than with the eye or the ear.
Videostroboscopic evaluation of laryngeal functioning is routinely and easily performed in a clinic setting using either a rigid or flexible fiberoptic endoscope. In order to perform rigid oral endoscopy, the patient is asked to protrude the tongue. The clinician holds the tongue as a rigid tube is inserted into the mouth. The tube or scope projects a high intensity light at a predetermined angle illuminating the structures to be observed and recorded. The advantages of this method are high illumination, a wide field of view and excellent imaging capability. The disadvantages are that the procedure interferes with normal speech production and there is some minor patient discomfort associated with the natural gag mechanism. However, the patient’s discomfort is minimized with the use of a topical anesthetic spray.
Flexible fiberoptic endoscopy is performed with a flexible tube which is inserted through the nasal passage. Again, a high intensity light is transmitted through the flexible scope, which illuminates the structures to be viewed by the clinician and/or recorded. In this procedure, one advantage is the excellent imaging of the vocal folds along with other structures of the oral cavity and throat. Since the small flexible scope is inserted through the nose, it does not interfere with the patient’s ability to speak during the examination. The disadvantages are that the image is smaller than the image provided by rigid endoscopy. In addition, the brightness of the image may be reduced. Again, possible patient discomfort is minimized with the use of a topical anesthetic spray administered into the nasal cavity. Both procedures allow patients to go about their daily routines following completion of the evaluation.
The entire examination takes approximately three to five minutes, depending upon the experience of the examiner and the cooperation of the patient. Correct interpretation of the results requires knowledge and familiarity with the anatomy and physiology of the larynx, phonation and the effect of potential pathologies on the vibratory functioning of the larynx. The technique is only one part of a clinical examination and is a valuable supplement to other currently used diagnostic procedures.
The VOICE HANDICAP INDEX (Jacobson, Johnson, Grywalski, et al., 1997) is a 30-item assessment tool designed to help the patient rate the severity of the functional, physical and emotional deficits he or she experiences on a daily basis as a result of a voice disorder.
A VOICE THERAPIST is a speech-language pathologist who has earned the designation “SLP” from studying disorders of the speaking, singing and acting voice as a concentration. Speech language pathologists must meet very specific requirements to be licensed, including a minimum of a master’s degree in speech language pathology, a clinical fellowship, which includes clinical training under the supervision of a practicing speech language pathologist who maintains a certificate of clinical competency, a passing grade on a national examination, in order to earn a certificate of clinical competency, and in 38 states, continuing education credits in order to maintain clinical licensure.
In addition, many speech language pathologists who have concentrated in voice also have a master’s degree in vocal music, and continue to enjoy performing.