Impact of Tussigenic Stimuli on Perceived Upper Airway Sensation and Motor Cough Response Following Total Laryngectomy

Abstract

Background: Total laryngectomy (TL) is standard intervention for carcinoma of the head and neck or, in cases of non-functional larynx, as a result of disease or radiation exposure. Laryngeal extirpation serves as a unique human model of both recurrent and superior laryngeal nerve section and offers insight into motor and sensory aspects of cough: both volitional and in response to tussigenic stimuli. While motor changes in cough function are expected among those status post-TL due to postoperative reconstruction of the upper airway, motor cough parameters have not been well described and sensory aspects of cough are unknown in this population, which provides insight into a vagal denervation model in humans. Methods: Data were collected from three groups totaling 80 adults (39 male), including 25 healthy younger adults (HYA), 27 healthy older adults (HOA), and 28 adults post-TL. Cough was elicited both upon command and in response to nebulized capsaicin. Outcome measures included urge to cough and cough airflows. Results: Kruskal-Wallis test showed that two of the three groups differed significantly by urge to cough χ 2 (2, N = 244) = 8.974, p = 0.011. Post hoc analysis showed that post-TL subjects had reduced perceived urge to cough at all concentrations of capsaicin (p < 0.05). Cough airflows were significantly reduced for post-TL subjects compared to healthy controls in all metrics except post-peak phase integral (PPPI) for which HOA and TLs were comparable under both volitional and capsaicin-induced conditions. Conclusions: These findings support the hypothesis that both cough airflow and sensations are significantly reduced in post-TL subjects when compared with HOA. Interestingly, HOA and post-TL subjects have comparably reduced UTC and cough airflows when compared to HYA. The only metric of cough airflow for which these groups differ is the PPPI, which may be a compensatory adaptation for reduced cough airflows and/or sensation.

A prospective examination of swallow and cough dysfunction after lung transplantation

“…This cohort of LT recipients who undergo denervation of the lower airway distal to anastomosis provides a unique contrast to published data in individuals undergoing total laryngectomy who lack laryngeal afferents. [49][50][51][52] The observation that UTC appears diminished in both these populations may support findings in animal studies where, irrespective of if cough is stimulated at the larynx or intrathoracic airway, lung-volume related and pulmonary vagal afferent feedback was associated with modulation of cough. 22 Our RR findings are consistent with previous reports in patients with pulmonary disease, 53,54 and further align with a scoping systematic review which suggested that elevated RR is a physiologic risk factor for aspiration.…”

“…No significant differences were observed in patient‐rated UTC across swallowing safety groups and at this point it does not appear another investigation on UTC in LT recipients is available for direct comparison. This cohort of LT recipients who undergo denervation of the lower airway distal to anastomosis provides a unique contrast to published data in individuals undergoing total laryngectomy who lack laryngeal afferents 49–52 . The observation that UTC appears diminished in both these populations may support findings in animal studies where, irrespective of if cough is stimulated at the larynx or intrathoracic airway, lung‐volume related and pulmonary vagal afferent feedback was associated with modulation of cough 22 …”

Changes in Cough Airflow and Acoustics After Injection Laryngoplasty

“…Fontana et al determined a reduction in PEFR and CVA in subjects with laryngectomy compared to age‐matched healthy subjects 27 . The decrease in PEFR with laryngectomy was further corroborated by Fullerton et al, 44 thus indicating a possible function of the larynx in catalyzing effective and maximal expiratory airflow during cough to achieve airway clearance.…”

Hypotussic cough in persons with dysphagia: biobehavioral interventions and pathways to clinical implementation

“…Further, dysphagia-related hypotussia is associated with increased rates of pneumonia, reintubation, hospital readmission, and costs of care (31,(34)(35)(36)(37)(38). Complex deficits across the continuum of airway protection (i.e., swallow to cough) co-occur in multiple patient populations including: Parkinson's disease (39, 40), amyotrophic lateral sclerosis [ALS; (23,(41)(42)(43)], multiple sclerosis (44), atypical parkinsonism (31), progressive supranuclear palsy [PSP, (45)], cerebellar ataxia (25), stroke (41,46), head and neck cancer (47)(48)(49), cerebral palsy (50), spinal cord injury (51), lung transplantation (52), and cardiac surgery (37). Thus, to improve health and quality of life for this large and heterogeneous group of patients, it is critical that rehabilitation efforts include cough (4,15,31,38).…”