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To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Laryngopedia By Bastian Medical Media

A Journal of Observational Laryngology

Clinical observations, anecdotes, case series, and conceptual frameworks for further exploration

About the Journal

When Mucus Seems to Be Causing Your Cough or Throat Clearing – But Isn’t

We all have experience trying to manage mucus that is causing us a problem. Sometimes, such as during an upper respiratory infection, our bodies over-produce mucus, in which case we cough it up, blow it out, or “dry it up” with decongestants. Other times, mucus may become thick and crusted, in which case we thin it out by drinking more fluids, using a humidifier and Neti pot, or taking over-the-counter mucolytics. And, if mucus becomes purulent, we treat it with antibiotics. Continue reading

Vocal Underdoer Syndrome: When Voice Rest or Restraint Only Hurts

By Robert W. Bastian, MD

For a voice clinician, it is helpful not only to place each medical disorder in its own unique diagnostic “basket,” but also to search for organizing concepts that might show what certain disorders have in common with each other.

For example, vocal nodules, vocal polyps, and vocal fold hemorrhage are three distinct diagnoses that could be found in three different people. Yet these “different” diagnoses can be understood and addressed better when placed together under a common banner: the vocal overdoer syndrome. That is, since each of these kinds of vocal fold injuries arises from excessive voice use (along with other injuries like capillary ectasia and epidermoid cyst), it is most helpful, when dealing with such an injury, to view the vocal overdoer syndrome as (almost always, but not exclusively) the primary diagnosis and the resultant injury as the secondary diagnosis.

Although it is now widely understood that many types of vocal fold injuries are caused by excessive voice use, it remains less clear to many voice clinicians that disorders can also occur because of vocal underuse. A person might underuse one’s voice for a variety of reasons: a personality that limits voice use; a false conclusion one has jumped to about his or her voice, triggering inappropriate, self-imposed voice rest; well-intentioned but misguided medical advice to conserve the voice; or a combination of these. All of these scenarios, when they lead to a voice problem, fall under the banner of what we call the vocal underdoer syndrome. Continue reading

Medical Jadedness and Treatment of Sensory Neuropathic Cough

By Robert W. Bastian, MD

People with sensory neuropathic cough often spend years searching in vain for a correct diagnosis and effective treatment. In a group of 110 consecutive patients diagnosed with sensory neuropathic cough by the author in 2005, the median duration of cough prior to diagnosis was 10 years, ranging from a few weeks to 62 years.

Such individuals will first visit their own primary care physician, and then an allergist, pulmonologist, gastroenterologist, and otolaryngologist. In each place, he or she may submit to a long list of tests, such as chest x-ray, various scans of the chest or sinuses, pulmonary function tests, allergy tests, bronchoscopy, esophagoscopy, 24-hour pH probe, and so forth. These tests are done to evaluate some “usual suspects,” for chronic cough—in particular, allergy, acid reflux, and cough-variant asthma.

Add to all of this that an individual with sensory neuropathic cough may have tried several to dozens of medications, including antihistamines, asthma inhalers, acid suppressors, antibiotics, cough suppressants, expectorants, and steroids—even when testing for the conditions for which those medications are used was negative. This leaves medicine chests cluttered with bottles of drugs that did not work. Continue reading

A Trail to Sensory Neuropathic Cough

By Robert W. Bastian, MD

A new clinical insight can be sparked when a physician encounters a series of patients in close succession whose stories overlap in some surprising way. This is an account of that sort, reviewing a trail of patients that led to understanding the clinical entity of sensory neuropathic cough1.

Before the late 1990s, when the fourth patient described below opened for me a new thought window and initiated a substantial caseload of sensory neuropathic cough, only an occasional patient—not more than one or two per year—would ask for help with a chronic cough of a diabolical, life-changing sort. Examination would reveal nothing to explain the cough. If not already done by a prior physician, some tests and then empiric treatments would follow. The focus was always on the “usual suspects”: allergy, acid reflux, and cough-variant asthma.

Nothing ever worked for prior physicians or for me, until I saw the following four patients within a few weeks of each other and a new concept appeared: coughing initiated by a primary neurogenic sensory disturbance, analogous to neuralgia. Continue reading

Early Vocal Cord Cancer: Remove with a Laser, or Radiate?

By Robert W. Bastian, MD

Patients who are diagnosed with early vocal cord cancer have two main treatment options to consider: laser surgery or radiation. There are quite a few factors to consider when weighing these two options, which can be confusing for the patient and challenging for the clinician to explain.

After 15 years of laryngology practice, I decided to create a single, codified overview on this subject, to help me teach more clearly and comprehensively when consulting with patients about this decision. Since creating that overview (which I also send home with patients as a handout), I’ve found it much easier to explain to patients the factors to consider when deciding between laser surgery and radiation to treat early vocal cord cancer. Below is that overview I created, in case it could help others who are consulting on or making this decision. Continue reading

The Use of Capsaicin for Sensory Neuropathic Cough

By Robert W. Bastian, MD

In recent years, a neurogenic form of chronic cough has been described in the literature, referred to variously as “sensory neuropathy presenting as chronic cough”1, “sensory neuropathic cough”2,3, “laryngeal sensory neuropathy”4, or simply “refractory chronic cough”5. It has been shown that sensory neuropathic cough (SNC) can be treated with certain neuralgia medications1,4,5,6,7,8. What has not yet been described, however, is the use of capsaicin spray as a possible treatment for SNC patients—an approach that may seem counter-intuitive, given that capsaicin is known in the pulmonary medicine literature as a means for provoking coughing for diagnostic or research reasons. Continue reading

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