or-gan-ic (or-’ga-nik) adjective, 1517
2 a : of, relating to, or arising in a bodily organ b : affecting the structure of the organism
Merriam Webster online dictionary
Nonorganic disorders of the larynx are habituations of a particular action. They do not arise from a structural change in an organ system, in this case, the larynx. However, they often start with a typical illness that then fails to resolve with the usual measures and within the usual length of time. There may be secondary gain involved - emotional, monetary or in relief from some obligation. This secondary gain may be conscious or unconscious. The action is usually stereotyped and the patient often has at their disposal only one strategy for maintaining their nonorganic illness. This depends on the length of the illness. The longer they have been treated for a presumed organic illness, the more strategies they will have mastered.
Typically, nonorganic illnesses approximate some organic illness, at least superficially.
- Habituated aphonia (may be perceived as an abductor spasmodic dysphonia)
- Habituated hoarseness (there are a variety of positions the larynx may be held in to generate an abnormal sounding voice)
- Habituated cough
- Mimicked spasmodic dysphonia (adductor, abductor or respiratory)
- Mimicked asthma (wheezing sounds may be generated from the trachea or the vocal folds may approximate during inspiration causing apparent “paradoxical vocal fold movement”)
- Inappropriate falsetto - (puberophonia in post pubertal males)
- Inappropriate straining or false fold phonation
- Inappropriate dysarthria
Quite often the illness starts with an organic disease that causes hoarseness but then continues for an extremely long period of time. For example bronchitis and laryngitis are common onsets. Presumably the vocal cords swell and the patient puts extra force into making swollen and stiff vocal cords vibrate. Then the swelling resolves, but the "extra effort" remains which is perceived as a dysphonia. Numerous diagnoses by multiple providers become common later in the illness.
The patient often presents with one strategy for maintaining a voice disorder. Falsetto voice, whispering or coarseness (false fold phonation) are common strategies. During the interview the patient may lapse into a normal voice (such as chest voice during puberophonia) particularly common with a vegetative sound such as produced by a laugh or a cough.
Articulation and resonance should be characteristics that are not affected in a non-neurologic organic illness of the larynx.
Character of an nonorganic patient
- sometimes gregarious and attention seeking
- manifest a la belle indifference or a cognitive - emotional dissociation. This is a glow in the eyes that does not match the usual emotional response to a debilitating disease. The most common example of this is when I sympathize with how badly things must be going because of this voice problem and this comment elicits sometimes quite a broad smile on the patients face, which is "la belle indifference".
- Talkativeness scale: any
- General
- Reading voice
- Typically this will be representative of the illness. Since the patient speaks all the time, their illness is most manifest during a speaking voice. Thus, this task establishes the manifestation of the disorder and then the physician checks to see if the voice remains consistent on other tasks.
- Pitch range
- While using the various tasks to determine pitch ceiling and floor, more of the patient’s normal voice may become evident. This “normal” voice can be replayed to the patient from the video.
- The patient will have difficulty reaching the same vocal ceiling with different tasks, because they are likely to have only one strategy for their voice disorder.
- Vegetative sounds
- The examiner listens for inadvertent sounds produced by the patient such as
- cough
- throat clearing
- laughter
- crying
- The disorder is often not consistent during these sounds
- Singing
- In a non singer, the patient may not previously have had the chance to sing. This will often come out in a different sound of voice.
- Chanting or humming can be helpful to elicit a normal voice
- Yelling voice
- Requesting a yell may elicit a quieter voice rather than louder. (paradoxical?)
- Demurring before a task. “You want me to yell?” “Yes” “Really yell?” “Yes” (the patient is demonstrating an awareness that they may not be consistent on this new task)
- Videolaryngeal exam
- normal anatomy with this voice disorder
- use caution if there is a finding, be sure it is consistent with the vocal pathology, otherwise it is likely a red herring
- distract patient to record normal phonation or breathing
- abnormal or paradoxical vocal fold motion may be recorded on the video and used as a biofeedback for the patient
- mimicked asthma - paradoxical collapse of the trachea with forced expiration and wheezing can be recorded on a deep flexible tracheoscopic examination. Simultaneous auscultation over the trachea and over peripheral lung fields reveals louder wheezing over the trachea - the opposite of actual asthma
- perform trial therapy and record either video or audio as appropriate
- Stroboscopy - often not necessary
- I believe medical interventions are generally best avoided with some exceptions
- Injections
- I have injected lidocaine blocking the recurrent laryngeal nerve temporarily. This alters the configuration of the larynx substantially by paralyzing one of the vocal cords. As the voice gradually recovers over about an hour a talented speech therapist can work with the patient to prevent the oversqueeze that is typical of many types on nonorganic dysphonia, particularly the ones labeled "muscle tension dysphonia".
- Some of my colleagues have injected Botox for a longer term alteration of the larynx. I have preferred a more direct approach with the positive and negative practice approach in conjunction with a speech therapist.
- Reassurance
- “Many, many of my patients have this type of problem. It often comes on after an illness or other trigger but it really does not matter what the cause it can be treated the same way. Stress can certainly aggravate the condition or bring it back on after some improvement.” Use “face saving” language. Emphasize that it is not important to know the cause of the disorder.
- It is often useful to have a family member present to document the condition and the normal voicing that can be obtained. Often family are part of the trigger.
- It is rare that these patients would need to see a counselor. If another illness were present such as depression, then a referral might be helpful.
- Trial therapy
- During or after the laryngeal exam, trial therapy may begin. The key is to alter the system. This breaks the strategy that is maintaining the nonorganic phonation. Chanting in a falsetto voice, yelling, manually repositioning the larynx can change the system the patient has developed. In a rare instance, a recurrent laryngeal nerve block can alter the system sufficiently to begin therapy.
- Mastery of normal and abnormal phonation
- Positive and negative practice provide the patient with a mechanism for treatment. For instance, if the patient is speaking in falsetto, get them into chest register and the have them move back and forth between registers. If they don’t easily move into chest register with coaching then manipulation of the larynx (holding it lower) may bring out the chest voice.
- Immediate return to normal activity
- Solidify and consolidate the improvement with Speech therapy. A marathon session early in treatment can be quite helpful. All members of the treatment team need to accept the nonorganic diagnosis otherwise treatment will not be successful as the patient latches onto another organic diagnosis.
- A quick return to work is important as well. If the patient is allowed to experiment, they may develop additional adaptive behaviors to maintain the nonorganic illness.
- Follow up
- A follow up visit in 3 - 6 weeks with a “graduation ceremony - condition cured” approach can aid in maintaining the improvement.
- Be positive about success during all phases of treatment.
- Caveat
- I always assume that the disorder is unconscious initially. For one, the disorder may have been reinforced as an organic disorder by previous examiners and how could a patient object to that diagnosis.
- Giving the patient the benefit of any doubt allows for recovery at a follow up visit.
- If the patient persists in maintaining the abnormal voice and the secondary gain is becoming quite obvious to everyone, then I will entertain other diagnoses such as malingering or Munchausen's symdrome.
Speech Therapy
- Immediate, intense therapy directed at correcting the nonorganic disorder is essential. The sooner, the better.
Avoid
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