Teaching Case 7: “Hypersensitive Larynx”

A 37 year old man has a history of episodic dyspnea over the past six months.  Cardiac and pulmonary evaluations have been normal including EKG, PFTs and chest CT.  He has not responded to albuterol, Nexium, Nasonex or Advair.  He was diagnosed with obstructive sleep apnea.  GI evaluation did not show signs of reflux but nonetheless he was prescribed BID proton pump therapy. 

The episodes of dyspnea last from one to six hours.  It feels like a gas bubble but belching does not seem to help.  He feels that he cannot take a deep breath and that dyspnea is definitely worse with speech.  It seems to be better in the supine position and with cold air exposure.  There is no correlation with foods.

Examination  is normal.  Allergy skin testing is negative.

Nasal Endoscopy/Laryngoscopy:

Diagnostic Impression:

Partial right vocal fold paresis and laryngeal hypersensitivity. Amitryptilline 10 mg qd started and within 2 days the patient felt about 90% better.  He was seen by a laryngologist who confirmed findings. Despite months of speech therapy he was unable to taper off of amitryptilline.

Clinical Pearls:
Dyspnea that worsens with speaking (rather than exercise) is an indication of a laryngeal disorder.