P., a 59-year-old woman painter and restorer, presented to the office sent by her ENT with an irritable larynx syndrome that had been present for several years, reporting classic symptoms such as recurrent cough and paradoxical laryngeal movement.
In the medical history P. reported that 'several upper respiratory tract infections have left me with a chronic cough'. Lately P. noticed that strong odors associated with chemicals, smoke, and paint were worsening her cough. Years earlier she had been diagnosed with asthma which she treated pharmacologically.
Last month she had a specialist visit to a medical center where pulmonologist and ENT diagnosed a laryngeal-pharyngeal reflux problem and identified this as the cause of her symptoms, suggesting a diet that P. began to follow.
As P. recounted the whole thing she was struck by coughing fits with a frequency of one about every 5-10 minutes, sometimes expectorating mucus or saliva.
I requested that she go to an ENT and phoniatrician to have a thorough laryngeal evaluation, and from the laryngeal examination performed with nasolaryngoscope, paradoxical mobility of the vocal cords at rest was observed without P. having any symptoms. On deep inhalation the vocal cords moved medially, with antero-medial and antero-posterior compression. When P. exhaled, the vocal cords abducted normally. During the guided 'sniffing' movement (then followed by propulsive exhalation), vocal cord movement was normalized, although each deep inhalation involved an abnormal adductor direction before abduction. No coughing occurred during the examination and no vocal stridor or inspiratory difficulty was ever experienced.
I performed osteopathic evaluation in which there was a descending functional pattern starting in the hypochondria region in conjunction with an ascending pattern with fulcrum in the tongue. The larynx functioned in clear superiority with slight lowering down to the level of the c.thyroid and was pastorally lodged very posteriorly, probably reducing esophageal space. The c. cricoid, on the other hand, much in accordance with the descending pattern, had predominantly inferior function with little return in exhalation. The cervical spine was reduced in its curve and poorly functional in its central pivot.
The physician assessed reflux in the last month through the IHR which gave 29 points out of 45 and then gave positivity (above 12 points is considered positive) and mucus was rated 4 on a scale of 0-5 in swallowing liquids and pills.
Peak, spectrum and vocal quality parameters were normal for sex and age, moderate strain and hoarseness were present rated 1 on a 5-point scale with 5 sign of severity.
Therapy consisting of coordinated osteopathic and ENT-logopedic interventions was divided into two phases:
Short term: proper functional recovery of the larynx by OMT and management of coughing accesses by speech exercises in which he was taught to swallow freely and slowly in response to coughing and to self-massage the laryngeal area.
Long-term: reflux reduction by OMT and combined drug therapy.