Julie Soprano arrives in the waiting area, breathing noisily. There is the temptation to pick up the phone and call 911 to ring an ambulance and have her taken back to the hospital. But after watching her for a few minutes, her breathing stays the same, a raspy noise with every breath in and out. She comes back to the examination room. She is able to speak, but her mother gives most of the history. Two weeks ago she developed trouble breathing and was admitted through the emergency room to the hospital in her hometown. She was breathing noisily then, and was given aggressive treatment for asthma, including nebulized epinephrine, steroids, and other inhalers. She was admitted to the Intensive Care Unit for two days and was also given anti-anxiety medication. Despite this rather significant intervention, she failed to improve. After two weeks of hospitalization with minimal improvement, she was sent to the laryngologist.
Inconsistencies in the Pattern
The principle behind diagnosing laryngeal (and all voice) disorders is knowing that each disease fits a pattern, with the exception of nonorganic illnesses. Diseases fit a pattern because each particular injury affects air movement through the vocal cords in the same way each time. For example, in a bilateral vocal cord paralysis, both cords tend to end up near each other in the middle of the larynx. This means there is very little space between them, whether for breathing or speaking. If you pass air between two vocal cords that are close together, they will vibrate. So a person with a bilateral paralysis will have noise when breathing in, noise when breathing out, and they will create sound during speech that is often normal in volume. These symptoms are based on the physical location of the vocal cords in a fixed position near each other.
Comparing Julie’s breathing to a patient with a bilateral paralysis reveals an incongruence for Julie. She is making noise breathing in, noise breathing out, and yet she is having great difficulty speaking. Fortunately for me, the diagnostician, Julie doesn’t know which symptoms go with which diseases. In nonorganic disorders, the symptoms are variable and inconsistent and I have already noted one inconsistency in Julie.
I turn on my recorder and listen to Julie speak. I ask her to perform a number of vocal tasks — reading, singing high and low notes, making a sound for as long as possible, yelling, coughing, and throat clearing. Since each of these vocal tasks has a specific result based on how the vocal cords are positioned and how well they are functioning, I begin to hear the inconsistencies in her exam. Her symptoms are not matching up with asthma. They do not match bilateral vocal cord paralysis either. Both these diagnoses could be entertained based on some of her symptoms.
For instance, she coughs just fine. Coughing normally would be odd sounding if the vocal cords were fixed close enough together to cause noise with every breath in and every breath out.
Diagnosis on Endoscopy
I insert my endoscope so that I can record Julie’s vocal folds. First, I observe breathing. Indeed, her vocal cords are very close together both on inspiration and on expiration. That tells me that a simple exam with an endoscope during her recent hospitalization could have alleviated all the “asthma” treatments, since asthma does not cause the vocal folds to come and rest together. The vocal cords are creating her wheezing sound while breathing.
Since I earlier heard a normal cough, I ask Julie to cough while recording the video. Julie’s vocal folds open completely during the cough, then promptly come together again. With one vocal task, we have eliminated the possibility that the vocal folds are paralyzed. We have also eliminated the possibility that they are scarred together. We have documented the source of the sound — her vocal folds, not her lungs.
Now that I know for certain that she has a safe airway — the vocal folds can open completely — I can ignore the noisy breathing as not dangerous.
Treatment
The treatment of Julie’s problem is beginning, even in the middle of the examination. I continue to record the movement of the vocal cords under various tasks — attempted high pitch, attempted low pitch, sniffing, throat clearing, humming. I may even hold onto Julie’s larynx with my finger and keep it in one position while she attempts various tasks, but above all, I am recording the exam.
I play back the video to Julie and her mother, explaining how well the vocal cords open and close. I assert that although I don’t know how the vocal cords came to be so close together, whatever got them to that position originally is now gone. We need only to retrain them to open with Julie’s control in order to restore Julie’s voice as well as her breathing. Interestingly she is a singer and actually had a competitive performance coming up later this week at school, from which she is presently excused because of her condition.
A nonorganic laryngeal disorder can mimic any other organic disorder, at least superficially. Typically a patient will not know all the symptoms for any given disease so the examination will have inconsistencies. One of the reasons nonorganic disorders so closely mimic organic disease is that frequently an organic disease starts the problem with the vocal cords. Then the secondary gain from being ill is so strong, that the patient avoids — consciously or unconsciously — getting better. It is more rewarding to stay ill than to get better.
I suspect that the relief Julie experienced from her initial illness (noisy breathing perhaps from a laryngitis that caused swelling of her larynx) included that she felt relieved that she would not have to compete at the upcoming vocal competition. She didn’t want to get well too soon, or she would have to perform.
The diagnosis and treatment are highly intertwined now because, if I can relieve Julie’s noisy breathing, my diagnosis is proven correct. To that end, I set Julie up to succeed. I review my video findings with Julie and her family, explaining the great relief I have experienced since her vocal cords can open all the way. Julie is now “trapped” in front of her family into improving.
Secondary gain is a basic human tendency. Responding to a reward is normal, not malicious, and Julie will stop the abnormal behavior when she consciously recognizes the behavior and recognizes that the behavior is causing pain and worry in others.
I attribute her initial illness to a probable laryngitis (organic or non-psychological cause) so that Julie is able to “save face.” She did not likely create the initial problem and having an explanation that she can provide to others to explain her illness allows for a comfortable way out.
I explain that this illness is a muscle problem. The muscles of the larynx have learned a specific way of tensioning the larynx, which may have been quite helpful when there was swelling present. However, now that the initial problem is resolved, the remaining problem is merely the muscle tightness.
If necessary, I reinsert the endoscope so that Julie can see her vocal cords moving and begin training. On whatever task that opens her vocal cords, I return to that task. I point out where Julie seems to have some control. In this case, coughing and sniffing open the cords. I have Julie perform those tasks while watching the video monitor. Since she has a difficult time with control, I emphasize first that she do the opposite of what we want. Squeeze the vocal folds even more tightly together, making the breathing sound even louder, followed by a sniff. She can then begin to feel the difference between very tight folds when making sound and the very open vocal folds when sniffing. I praise her for any progress she makes, so that there is at least some benefit to improving — my praise.
The noisy breathing begins to subside. The vocal folds gradually loosen and Julie’s voice gradually improves. She spends about two hours with a speech therapist to further practice this tensioning and loosening. When I re-examine her the next morning, the noisy breathing is gone, the speaking voice is entirely normal, and the vocal folds move completely normally on endoscopic examination.
There are two additional steps for me. I inform Julie and her family that there is a high probability that this condition will return at some point. I ask Julie to demonstrate the noisy breathing again and then stop it at will. She now has control over the problem. She should practice tightening and loosening the vocal folds, so should something inadvertently trigger the noisy breathing again, she will have a method for restoring her voice and breathing.
Additionally, I correspond with all of her other physicians (there are many; she had consults during her illness with allergists, pulmonologists, otolaryngologists, and others). Everyone can learn from this experience of misdiagnosis. Also, should any one of her physicians see a similar illness occurring again, they will have a higher suspicion that nonorganic illness may be playing a role and not be distracted by the inconsistencies.
The difficulty with diagnosing nonorganic disease is that nonorganic laryngeal disorders mimic almost all the other laryngeal conditions. They can mimic spasms of the voice, weakness, double pitches, speaking in falsetto only (called puberophonia in males, although the condition occurs in females as well) or complete aphonia (no sound at all).
Although nonorganic conditions show up elsewhere in the body, there is probably some propensity for them to show up in the larynx. These conditions are the extensive modification of sound that is normally used to primarily convey emotion. So disorders that affect one’s psyche may have a high propensity to affect one’s voice.
What You Learned
- Nonorganic disorders can manifest as breathing problems, not only voice problems — the larynx, not the lungs, may be the source of noisy breathing.
- The key diagnostic tool is inconsistency: symptoms that don’t fit any single organic pattern. Julie breathed noisily on every breath yet coughed normally — an impossible combination in fixed bilateral paralysis.
- A normal cough on endoscopy immediately eliminates paralysis and scarring; it also documents where the vocal folds can open fully.
- Diagnosis and treatment are intertwined: if the clinician relieves the symptom during the examination, the diagnosis is simultaneously confirmed.
- Giving the patient a face-saving organic explanation for the initial illness clears the way for recovery without shame.
- Always correspond with all physicians involved; this raises suspicion for future episodes and prevents escalating treatments for a nonorganic condition.
- The larynx has a special propensity for nonorganic disorders because it is the primary instrument of emotional expression.