We present the case of a 76 year old female inpatient who suffered from a chronic intractable
cough which arose simultaneously to a severe major depression and was secondary to an exorbitant psychological distress.
Chronic cough had never been experienced before and was initially considered to have a mere psychogenic origin since a comprehensive and guideline-based diagnostic screening did not reveal any underlying somatic cause. However, several factors cast doubt on the solitary psychic genesis of the
chronic cough: i) occurrence immediately after a penetrant cold, ii) embedding in other complaints of laryngeal hyperreagibility (larynx irritable), such as persistent
globus pharyngeus sensation, throat clearing and episodic
dysphonia, iii) first occurrence on old life, iv) erupting from sleep as well, v) persistence despite remission of the major depression, and v) no sustaining benefit from specific psychotherapy and
speech therapy. Therefore, diagnostics were extended to apparative tools for objective evaluation of swallowing by using fiberoptic videoendoscopic (FEES) and videofluoroscopic (VFS) techniques, which revealed signs of laryngeal neuropathy but without evidence of penetration or aspiration. A co-existing small
goiter and an
impaired glucose tolerance along with a putative intracellular
vitamin B12 or
folate deficiency (as indirectly derived from an apparent
hyperhomocysteinemia) were assumed to be responsible for the neuropathy and underwent specific treatments. The
impaired glucose tolerance and putative
vitamin deficit were compatible with a distal symmetric sensorimotoric, even subclinical
polyneuropathy of the lower extremities. The larynx irritable improved under
gabapentin being confirmed by
drug removals several times, and finally calmed down almost completely under
gabapentin, which was in line with the scant literature of this topic. Re-examination of the larynx per FEES nine months later showed no deficits any more under the well-tolerated treatment (
gabapentin,
levothyroxine,
vitamin B12 and
folic acid substitution,
weight reduction and physical training). All in all, the larynx irritable as well as the
chronic cough were most probably induced by a laryngeal neuropathy and were not solely of psychic origin. Due to good treatment options a larynx irritable should be regularly taken into consideration of the investigation of intractable
chronic cough. Therefore, an apparative evaluation of deglutition is recommended in the diagnostic toolbox of
chronic cough - even if embedded in a
psychiatric disorder or distress - before diagnosing a sole psychic origin. An hypothetical scheme of the development of a larynx irritable caused by neuropathic and non-neuropathic ("nociceptive") conditions is proposed.