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Invited Commentary
April 30, 2020

The Puzzle of Medically Unexplained Symptoms—A Holistic View of the Patient With Laryngeal Symptoms

Author Affiliations
  • 1Departments of Otolaryngology and Psychology, University of Minnesota, Minneapolis
  • 2Department of Speech, Language and Hearing Sciences, University of Missouri, Columbia
  • 3Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
  • 4Editor, JAMA Otolaryngology–Head and Neck Surgery
JAMA Otolaryngol Head Neck Surg. Published online April 30, 2020. doi:10.1001/jamaoto.2020.0559

Functional laryngeal and airway disorders are characterized by apparently normal anatomy and neurological function accompanied by clinically significant symptoms, which can include dysphonia, dysphagia, globus sensation, and dyspnea. These disorders are often diagnoses of exclusion, since the presenting symptoms can also accompany important anatomic and neurologic abnormalities that must be ruled out. Primary muscle tension dysphonia (MTD), also often called functional dysphonia or hyperfunctional dysphonia, presents with various forms of laryngeal muscular dysregulation during voice and speech production and remains a voice disorder without established pathophysiology. Some signs and symptoms may be observable during the examination (eg, supraglottic hyperfunction, perceived vocal strain), while others may be elusive (eg, vocal fatigue, stress-induced hyperfunction). Functional airway disorders such as paradoxical vocal fold motion disorder (sometimes also called vocal cord dysfunction) are characterized by dysfunctional respiratory/laryngeal coordination. These can lead to dynamic airway narrowing at the glottis and shortness of breath despite a neurologically normal larynx. Functional laryngeal and airway disorders are frequently associated with psychological distress, including depression, anxiety, and somatic concerns. Somatic concerns involving other parts of the body are also common in patients with MTD and are associated with heightened medical costs, which drive up the costs of health care and further burden patients, who may undergo numerous expensive evaluations, tests, and procedures owing to their symptoms.

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