The Irritable Larynx

Controlling Chronic Cough and PVFM

Most referrals that Mary Sandage, MA, CCC-SLP, receives for chronic cough and paradoxical vocal fold motion (PVFM) do not come from otolaryngologists. They are usually sent by asthma and allergy specialists, pulmonology specialists, sports medicine physicians and athletic trainers. The referral that puts a smile on her face, though, is the one she gets from a pulmonary specialist.

"The pulmonary physician has already done a chest X-ray and flow-volume loops to rule asthma in or out," said Sandage, adjunct clinical faculty in the Department of Communication Disorders and a doctoral candidate in the Department of Kinesiology at Auburn University in Auburn, AL. "I'm more confident moving forward if I know that a thorough pulmonary assessment has been done. That has to happen before I see the patient because I want to make sure my behavioral intervention is going to work."

Asthma that hasn't been definitively ruled in or out, or was untreated or under-treated, can make things difficult for the speech-language pathologist.

An otolaryngologist must examine the vocal folds for pathologies that can cause chronic cough or PVFM. "Vocal folds need to be imaged," Sandage told ADVANCE. "One of the challenges with this disorder is that people think, 'I'm good at this; why bother?' You might be missing something big that needs medical intervention."

Behavioral intervention by a speech-language pathologist for chronic cough once was overlooked, but it has proved invaluable in treatment.

Sandage's rationale for treating chronic cough and PVFM is based on a 1999 research paper about neuroplastic changes that can result from an upper-airway response to an etiology through an environmental agent.1The most common etiologies of chronic cough are reflux, asthma and post-nasal drip.

Reflux and asthma are closely related, she said. "Having reflux can make asthma worse, and asthma medications can make reflux worse. A lot of patients end up with cough for an extended period of time because the physician is only treating one thing at a time instead of treating everything at once."

The most common etiologies for PVFM are upper-airway irritants, neurogenic disorders and psychological conditions. Reflux irritates the upper airway, triggering it to close. Other upper-airway irritants are post-nasal drip and inhaled allergens, such as chemical fumes and dust particles.

Neurogenic conditions include focal laryngeal dystonia and brainstem compression. "A mass in the brainstem could cause this behavior," said Sandage. PVFM also has been observed in patients with cerebral palsy, stroke, amyotrophic lateral sclerosis (ALS), and some movement disorders.

Among the psychological conditions that can cause the condition is anxiety, which differs from a panic attack. People who experience both panic attacks and PVFM report the two events have distinctive sensations.

"PVFM can be a challenging diagnosis to make if you are not familiar with the condition," she said. Its neurologic presentation differs from an etiology of upper-airway irritation in that the patient has persistent difficulty inhaling while awake. Because it is not comprised of discrete breathing attacks, behavioral intervention typically is not warranted.

"Patients who have trouble breathing in throughout the day but have no trouble breathing during sleep should be referred for a comprehensive neurologic assessment," Sandage said.

The first step of a behavioral approach to chronic cough is to improve the laryngeal environment. Patients should eliminate anything that aggravates the laryngeal tissue, such as menthol cough drops and gargling. In addition, they should switch from mouth breathing to nose breathing and reduce exposure to dry environments. For example, many workplaces have heating vents that force out dry air.

Patients also should avoid food and beverages that promote reflux, including chocolate, fried and highly acidic foods, alcohol, caffeine and carbonated beverages. They should eat meals more than three or four hours before bedtime and should not engage in strenuous activities after eating.

Clothing that can constrict the midsection of the body, such as belts and control-top pantyhose, should be loosened or not worn, as the pressure can contribute to reflux. Patients should increase the ambient humidity in their home, drink more water, and eat wet snacks, which add moisture to the mouth and throat.

Physicians can suggest ways to make environmental changes, as well as recommend an appropriate reflux medicine.

Educating patients about the behavioral aspects of chronic cough is extremely important, noted Sandage. "They need to be aware of the physiological precursor to the cough. What feeling makes them want to cough-a tickle, a dry feeling? Are they regurgitating food into their throat?"

As soon as they notice the trigger, and before they get to the point where they cough, patients can do something to inhibit it, she said. "I have a list of things they can choose from: sucking on ice chips, taking a sip of cold water, swallowing instead of coughing, counting to five to see if the urge passes, or breathing in through the nose."

Individuals can work to change their habits through focused practice time early in the day. Some people only require 10 minutes. Others may need to practice five minutes every hour of the day, particularly those dealing with an irritating dry cough. "This doesn't work well for people who have an inconsistent, sudden, severe cough," she said.

To combat PVFM patients needs to master a breathing recovery exercise. Paying attention to triggers helps to sidestep an event. When they sense an event is about to occur, they should take a quick, hard sniff through the nose and then exhale completely through the mouth.

"The breath is not high in the chest but low in the belly, followed by a long exhale on an /s/ or /sh/ sound," Sandage explained. "The person must exhale all the way, or they may feel like they are going to pass out. If they do that until their throat is relaxed and open, they are not going to have trouble and can go back to regular breathing."

Recovery varies depending on the person. Some people can fix it with one cycle, while others may need 15 to 30 minutes to focus on their breathing.

"Some people have 25 events a day, some have one event a week, and some have an event once a month. A lot of people are afraid they are going to pass out or even die," she said. Such a thought is a natural fear response to not understanding what is going on.

"That's why it is so tricky," she said. "There has been a bias toward thinking it is solely a psychological disorder at the expense of overlooking obvious physiologic triggers."

Part of the challenge is that intervention for asthma and reflux may not have been sufficient for a patient. "Maybe asthma was treated, but that didn't fix the problem, so asthma intervention stopped. Then reflux was treated, but that didn't seem to help, so it was stopped," Sandage said. "The key is to make sure the intervention is long enough and complete enough that the person actually makes progress."

Treating this highly motivated population requires at least three clinic visits. During the first visit, the patient undergoes an evaluation and begins intervention. A week later the speech-language pathologist tweaks the intervention if necessary. A month later the patient returns for a check-up so the clinician can make sure the individual is making progress.


1. Morrison, M., Rammage, L., Emami, A.J. (1999). The irritable larynx syndrome. Journal of Voice, 13 (3): 447-55.


• Irwin, R.S., Boulet, L.P., et al. (1998). Managing cough as a defense mechanism and as a symptom. Chest, 114 (2 Suppl. Managing): 133S-181S.

• Maschka, D.A., Bauman, N.M., et al. (1997). A classification scheme for paradoxical vocal cord motion. Laryngoscope, 107 (11 Pt. I): 1429-35.

• Matthers-Schmidt, B.A. (2001). Paradoxical vocal fold motion: A tutorial on a complex disorder and the speech-language pathologist's role. American Journal of Speech-Language Pathology, 10 (2): 111.

• Sandage, M.J., Zelazny, S.K. (2004). Paradoxical vocal fold motion in children and adolescents. Language, Speech, and Hearing Services in Schools, 35 (4): 353-62.

• Vertigan, A.E., Theodoros, D.G., Gibson, P.G. (2006). Efficacy of speech pathology management for chronic cough: A randomised placebo controlled trial of treatment efficacy. Thorax, 61 (12): 1065-69.

For More Information

• Mary Sandage,

Jason Mosheim is a Senior Associate Editor at ADVANCE.

Cover Story Archives

Thank you, a very informative paper. I have just ventured into this area and welcome all suggestions on how to move forward/improve my service. My referrals are also coming from a respiratory team!

Gayle Reynolds,  Snr SLT,  Peamount HealthcareMarch 19, 2014
Dublin, Ireland

In paragraph 11 you state:

Because it is not comprised of discrete breathing attacks, behavioral intervention typically is not warranted.

The word you want is composed, not comprised.

gerald May 23, 2013


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