Laryngeal Recalibration Therapy in Clinical Practice for Laryngopharyngeal Symptoms

Background

Nearly 20% of US adults experience chronic laryngopharyngeal symptoms such as voice change, sore throat, throat clearing and cough.¹ A myriad of mechanisms can trigger laryngopharyngeal symptoms such as laryngitis, voice strain, environmental irritants and reflux of gastric contents. In clinical practice, gastro-esophageal reflux is often empirically implicated as the source of laryngopharyngeal symptoms, referred to as laryngopharyngeal reflux (LPR), and as a result, acid suppression with proton pump inhibitor (PPI) therapy is the primary treatment strategy. This approach is ineffective because laryngopharyngeal symptoms are poorly responsive to acid suppression for many reasons. Consequently, patients typically seek further evaluation - on average 10 consultations and 6 tests - yet rarely achieve relief.² Current ineffective approaches significantly impair patient quality of life (e.g., psychosocial status, social functioning, well-being) and contribute to $5,438/patient, equating to over $50 billion in annual health care costs.²

Regardless of whether true LPR is an etiology of chronic laryngopharyngeal symptoms, the persistence of laryngopharyngeal symptoms is often related to laryngeal-behavioral processes (Figure 1). Symptoms such as cough and throat clearing are hyper-responsive behaviors that can result from local irritation (e.g., refluxate) and heightened sympathetic tone. It may affect voice quality, create laryngeal tension, perpetuate globus, alter swallowing and cause respiratory distress.^3,4 In addition to hyper-responsive behaviors, the chronicity of laryngeal symptoms elevates cognitive awareness, often confounding deleterious habits and symptom burden.⁵ Studies identify elevated laryngeal-specific anxiety and hypervigilance in symptomatic patients, including those with and without evidence of pathologic GERD.^5,6 Laryngeal-specific anxiety and hypervigilance are associated with overall anxiety, depression and quality of life impairment.

Figure 1.

Laryngeal behavioral processes perpetuate laryngopharyngeal symptoms. Multiple etiologies can trigger laryngeal behavioral processes and gastro-esophageal reflux is not always the source.

The intersection among cognitive awareness, laryngeal symptom burden, and laryngeal responses represents an important therapeutic target. Unfortunately, the current paradigm for LPR largely ignores the interplay of psychological stressors and behavioral patterns on symptom burden.⁷ This clinical gap and uninvestigated pathway is an opportunity to help patients. Improving communication between laryngology and gastroenterology is anticipated to forge treatment options. A preliminary step to target appropriate etiologies of laryngopharyngeal symptoms was developed collaboratively among GI, psychology and speech-language pathology. The working protocol is called laryngeal recalibration therapy (LRT).

Laryngeal Recalibration Therapy

Laryngeal recalibration therapy (LRT) expediently and comprehensively integrates mechanical desensitization techniques and cognitive recalibration principles to attenuate hyper-responsive laryngeal behaviors and cognitive processes. LRT is provided by an SLP during a 45-to-60 minute session, and is traditionally well-covered by insurance. The three-pronged LRT approach consists of usual laryngeal biomechanical modification and two novel elements: heart rate variability (HRV) biofeedback and cognitive recalibration. ⁸(Figure 2).

Figure 2.

Laryngeal Recalibration Therapy provides SLP directed LRT (laryngeal biomechanical modification & cognitive guidance) to attenuate hyper-responsive behaviors, voice dysfunction, laryngeal sensitivity, & hypervigilance/anxiety. Anti-reflux strategies are recommended to those with proven GERD

Laryngeal Biomechanical Modification:

Laryngeal behavior dysregulation is common when patients experience laryngopharyngeal symptoms. ^9,10 Functional limitations can include voice change, cough, throat-clearing, respiratory and swallowing dysfunction. A specialized SLP, often housed within a multidisciplinary laryngology clinic, is well-versed in techniques that regulate these patterns. Their interventions are effectively delivered, and have been shown in certain populations to be superior to empiric reflux medication trials for laryngopharyngeal symptom improvement.^9,10 Attenuating hyper-responsive patterns is executed by highlighting preceding triggers, helping individuals develop awareness, suppressing habitual cough or throat-clearing, restoring normal respiratory flow, balancing voice resonance and promoting healthful swallowing patterns.

Heart Rate Variability Biofeedback:

Novel services, still within an SLP’s purview, can incorporate systemic desensitization and cognitive reframing. HRV biofeedback training is an intervention gaining traction for management of chronic diseases. The rationale for its use stems from the idea that HRV is a measure of autonomic function and overall health, with high HRV indicating adaptability of the cardiac system’s reaction to stress.¹¹ Evidence also suggests that a link exists between emotions and HRV. This supports the idea that HRV biofeedback training could improve vagal functioning, HRV and ultimately emotional regulation.¹¹ These theories were supported in a systematic review by Fournie et al.. Among the 29 articles reviewed, they found that HRV biofeedback was effective in patients with hypertension, inflammatory states, asthma disorders, depression, anxiety, sleep disturbance and pain. HRV biofeedback was also associated with improved quality of life.¹¹

Cognitive Recalibration:

A strong body of evidence demonstrates that enhanced cognitive awareness is modifiable using cognitive recalibration interventions, such as acceptance and commitment therapy.¹² These interventions are not “talk therapies,” traditionally delivered by a mental health provider and most individuals do not have psychiatric diagnoses. In other highly prevalent disorders of brain-gut interaction such as irritable bowel syndrome, the research robustly demonstrates behavioral therapies improve symptoms.

Laryngeal Recalibration Therapy Framework:

As such, a working framework was developed to encompass typical and novel treatment for laryngopharyngeal symptoms. The multi-pronged approach shifts laryngeal biomechanics while talking, breathing and swallowing while simultaneously targeting central processes with heart rate variability biofeedback and cognitive reframing. Each aspect produces quantifiable change: cough and throat-clearing frequency, normalized voice aerodynamics and acoustics, higher heart rate variability and enhanced cognitive flexibility. In an initial study of LRT, sixty-five enrolled patients with chronic laryngopharyngeal symptoms underwent at least two or more SLP- directed sessions of therapy. In the end, 85% of patients met the endpoint of laryngopharyngeal symptom response. This robust response rate is significantly higher than traditional therapies and maintained among patients without evidence of true LPR as well as those with GERD and likely LPR. ¹³

Laryngeal Recalibration Therapy in Clinical Practice

The working framework for LRT is detailed in Table 1. Based on clinical and research experiences to date, LRT is best suited for adult patients with chronic laryngopharyngeal symptoms that are accepting of behavioral interventions. SLPs are not mental health specialists, and thus patients in need of health psychology or with active psychiatric conditions should be referred to a mental health specialist. It is recommended that patients participate in approximately three sessions of LRT, each with distinct elements of mechanical alterations, HRV biofeedback and cognitive counseling.

Table 1.

Components of Laryngeal Recalibration Therapy

Voice Therapy	HRV Biofeedback	Cognitive Recalibration
Start with voice therapy (VT) and an assessment of the patient’s baseline symptoms 1. Discuss laryngeal sensations. 2. Quantify throat clearing and/or cough frequency. 3. Examine voice production: balanced, pressed, disengaged, standardized rating. 4. Observe respiratory patterns,screen for paradoxical vocal fold movement and laryngospasm. 5. Screen for dysphagia including functional disorders such as piece-meal and tension-laden 6. Provide suppression and desensitization for throat clearing and cough. 7. Offer prophylaxis and reversal maneuvers for dyspneic events. Repeat the above steps at each subsequent visit.	The HRV biofeedback used in this treatment is a modified version based on Leher et al., 2013 (See: https://psycnet.apa.org/record/2013-35584-004) The goal is to progressively slow the patient’s respiration rate over time. For some patients this may be uncomfortable to reduce too quickly, so it is best to follow the patient’s lead to reduce the risks of anxiety. Use a respiratory pacer via any commercially available device that measures HRV either with a chest strap or earlobe clip and has software or an app to give real-time feedback to the patient.	The cognitive recalibration (CR) used is based on Cognitive Remediation Therapy (CRT) and Acceptance and Commitment Therapy (ACT). A full CRT protocol with several exercises can be found here: https://img3.reoveme.com/m/243251c42ccb2de4.pdf. Cognitive Recalibration Exercises by visit: 1a. Stroop Task, choose 3 from CRT protocol 1b. Illusions Task, use all 3 from CRT protocol 1c. Cognitive defusion (see: https://positivepsychology.com/act-worksheets/ Milk Milk Milk exercise). Replace milk with word or phrase related to LPR symptoms. 2a. Complex Pictures, choose 3 from CRT protocol 2b. Goals and Values Exercise (See: https://positive.b-cdn.net/wp-content/uploads/2020/11/Personal-Values-Worksheet.pdf and https://positive.b-cdn.net/wp-content/uploads/2020/11/Commitment-Obstacles-and-Strategies-Worksheet.pdf) 3a. “Walking in the rain” exercise (see: https://www.moodcafe.co.uk/media/30517/Acceptance%20and%20Commitment%20Therapy%20for%20Physical%20Health%20Conditions.pdf)
Key components of each visit
Document frequency of each laryngeal symptom.	Psychoeducation: why breath work can help LPR.	Psychoeducation: how thoughts can impact how one experiences LPR symptoms.
Assess persistent issues that affectthroat sensations.	Model slow, abdominal breathing.	Use online resources from ACT and CRT to guide discussions with patient
Gauge skill acquisition and confidence in using skills day-to-day.	Encourage 10–20 minutes of home practice every day and discuss barriers.	Link thinking styles to experience with LPR symptoms.
Inquire about perceived percentage improved in laryngeal symptoms.	Review HRV metrics and discuss trends including symptom changes.	Evaluate shifts in perspectives about LPR symptoms.
Assess insights gained from VT exercises.	Solicit feedback on experience with HRV.	Assess insights gained from the CR exercises.

In gastroenterology, patients are often referred for evaluation of LPR. An initial decision point for clinicians can be whether the patient is experiencing concomitant esophageal and laryngopharyngeal symptoms or isolated laryngopharyngeal symptoms. Concomitant esophageal symptoms include esophageal reflux-like symptoms such as heartburn or regurgitation. In the case of isolated laryngopharyngeal symptoms, the likelihood of GERD is lower, and referral for LRT may be considered early in management. This care is typically preceded by diagnostic testing which may include laryngoscopy, videostroboscopy, fluoroscopic and endoscopic swallowing studies. LRT can be performed in tandem or prior to further GI evaluation. When esophageal symptoms are present, it is advised to first trial approximately 8 weeks of anti-secretory therapy, lifestyle and dietary modifications, reserving LRT referrals for refractory laryngopharyngeal symptoms (Figure 3).

Figure 3.

Clinical framework to determine role of laryngeal recalibration therapy for the patient with chronic laryngopharyngeal symptoms

Summary:

LRT is a novel, accessible and non-invasive treatment that addresses laryngeal behavioral processes in patients with chronic laryngopharyngeal symptoms. It is beneficial for patients with and without pathologic GERD. Pathologic GERD, even when controlled by medical management, can fuel recalcitrant laryngopharyngeal problems due to overlapping hyper responsive and hypersensitive laryngeal processes. For these individuals, it is advised that they consult with a specialized SLP who can perform a multifaceted intervention addressing laryngeal biomechanics, vagal modulation and cognitive framing as designed in this LRT model.