What is a chronic cough?
A chronic cough is defined as a cough longer than 8 weeks. If a person has a cough lasting for longer than 8 weeks he/she should get evaluated by an otolaryngologist and speech language pathologist specialized in voice and chronic cough.
Why does chronic cough consistently stump medical professionals?! We often see patients in our voice clinic who are at the end of their road. They’ve seen a million physicians and have tried a million and one treatments, to no avail, with no benefit. This is because there can be a number of reasons for a chronic cough. We have to first rule out acute causes (for example, infection/viral causes). But the next culprits related to chronic cough are reflux (even silent reflux called LPR), allergies, or neurogenic causes (for example over-stimulation of the nerves that control the larynx).
Chronic cough is a type of Vocal Cord Dysfunction, which means that the vocal folds (aka vocal cords) are moving in a way that they should not be moving. In chronic cough, this means that the vocal cords are hyper-stimulated by certain sensory “triggers” that normally should not make us cough. These triggers can often be things like cold air, changes in temperature, strong smells, stress, and talking.
So what do we do when a person with chronic cough enters our office?
Both myself and the otolaryngologist (specialized ENT) will do a thorough evaluation. We will look at the vocal folds in motion to see if there is any abnormalities with the vocal folds themselves or with the way they vibrate to make sound. We will also look to see if there is any extraneous movement of the vocal cords during breathing when there should not be.
We will look for notes from physicians such as pulmonologists and gastroenterology to see if the patient has had full work-ups to rule out things like asthma, test for reflux and to determine if the patient has any allergies that are not yet fully under control.
We’ll ask the patient many differentially diagnosing questions such as when does it occur most frequently, what makes the cough better or worse, are they frequent dry coughs or full blown coughing fits?
So then what?
I first education. Why is the chronic cough occurring with their particular case picture? We’ll go over everything from an anatomical, physiological standpoint. We’ll also start to discuss things like control and gaining control over the cough. We’ll address psychosocial symptoms such as fear of not being able to breathe during the cough, frustration, embarrassment and stress surrounding the chronic cough.
I generally use a combination of breathing retraining techniques to teach the individual how to both prevent and suppress a cough, vocal hygiene for reducing laryngeal triggers & attempting to desensitize the larynx, education to increase education on physiology, ability to recognize sensation triggers prior to cough, and control certain aspects of cough, and voice therapy as necessary (i.e. if cough worsens with talking and/or if there is an underlying vocal pathology contributing to cough (i.e. Muscle tension dysphonia, vocal fold atrophy, reflux etc). I take an approach that focuses both on preventing the cough onset and making it overall less likely to be a triggered response, but also in shifting out of a coughing fit after initiation.
An overarching goal is to replace the cough behavior with alternative behaviors and to desensitize the larynx so that it is overall less triggered to engage in a cyclical cough response. We attempt to get patients out of the constant cycle of cough, which causes further laryngeal irritation and sensitivity and perpetuates more coughing.
Key factors in this are practice on the patient’s side, increasing awareness, and gradually establishing control over the cough.
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