Bilateral Superior Laryngeal Nerve Block to Manage Refractory Chronic Cough

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology-head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm delighted to be joined by a returning guest, Dr. Will Tierney, one of my colleagues in our Laryngology Division and in the Voice Center. Dr. Tierney, welcome back to Head and Neck Innovations.

William Tierney: Thank you, Paul.

Paul Bryson: Well, I encourage everyone to go back and listen to Dr. Tierney's previous episode titled Speaking Clearer: Updates on Vocal Cord Paralysis Treatment. For our new listeners, let's start by having you share some background on yourself, where you're from, where you trained, and how you came to Cleveland Clinic.

William Tierney: Thanks. It's a pleasure to be back, and I've been at the Cleveland Clinic now for almost 15 years. I grew up in Northern California, went to school at UC Berkeley, and then came out here to do grad school at Case Western Reserve University in applied human anatomy. I did my medical degree at the Cleveland Clinic Lerner College of Medicine, and then my residency here at the Cleveland Clinic. Throughout that time period, I completed a master's degree in clinical research science, and my thesis was on limiting the risks of in-office procedures as compared to operative procedures in laryngology. So I've been working with Paul on that and other research topics now for over a decade. I did my fellowship at the Vanderbilt Voice Center in Laryngology and Care of the Professional Voice, and worked on chronic cough airway reconstruction and professional voice use for a year before accepting a position back here at the Cleveland Clinic to rejoin one of the best teams I've ever worked on.

Paul Bryson: Well, it's great to have you back. As you know, it's a constant delight that we get to do research together, take care of patients together, and then just see your clinical and professional growth over the years has really been gratifying just from a colleague standpoint. So it's nice to have you back on the podcast as we talk about another novel treatment option that we've been working on as a group for patients for a while.

Our team recently published a paper in The Laryngoscope titled The Role of Bilateral Superior Laryngeal Nerve Block in Managing Refractory Chronic Cough, and I wanted to see if you'd be able to talk about this work, but also I think it's a good time for us to provide the listener with a little background on chronic refractory cough. As you know, the complaint of cough is something that many people, most people will experience over the course of their lives. But if you can, before we get into this research, give the listener just some background on what is chronic cough and what is chronic refractory cough and how do we work as a team to care for these patients?

William Tierney: Yeah, so cough is a really interesting problem within our medical system and for mammals and human beings, but it is the most common reason that people cite as their chief complaint when they see a doctor in the United States. So the most common chief complaint of chronic refractory cough is when people have had this cough for four months. We've tested some things, we've ruled out some of the common reasons that people have cough and none of those things have worked and they're still coughing.

Paul Bryson: And for the list of what are some of the common things that cause cough?

William Tierney: Yeah, so the common sort of, we know that a lot of things cause us to cough, and I think this is a universal experience. Everyone coughs, and so we can relate to many of them. So the most common reasons are things like pulmonary infections, upper respiratory infections, those all cause cough. Everyone's had a cold and had a cough. But then reasons for chronic cough where it lasts longer than the acute phase are asthma, allergies, pulmonary problems such as lesions in the lung or chronic pulmonary disease, COPD falls in there somewhere. And then postnasal drip associated with allergy and then also-

Paul Bryson: And chronic sinus disease too-

William Tierney: Chronic sinus disease. And then also there's a family of laryngology diseases, which include things like nodules, polyps, granulomas, which can cause cough too, which is how we usually see these people initially is to kind of look into, hey, could you be coughing because of your laryngeal disease? So let's say you go through the workup for all of these things and none of them come back positive or let's say you have a couple of the things, but you max out on the treatment options available and are still coughing. Then we put patients into this category of chronic refractory cough where they're refractory to either treatment or we've ruled out causes, and this can be a really challenging problem. So chronic cough is as common as 12% of the adult population, and the treatment options available for chronic refractory cough are, there's a cough suppression behavioral therapy that's usually performed by a speech and language pathologist.

It's pretty well studied and fairly effective. I think about half of people get a really meaningful benefit. There's also neuromodulatory therapy, which is where we use a medication to decrease the cough reflex, and that's done with a family of drugs called neuromodulators. And the efficacy of that is somewhere in the 40 to 60% range based on the literature with a lot of people having some impact on their cough, but not a complete resolution. And so I kind of simplify this all down to somewhere around 50% of people get a good response from that.

Paul Bryson: It can be trial and error with the neuromodulators.

William Tierney: Right. And there's several different medications. They all have their own side effect profile. Some are tolerated better than others by different individuals either in isolation or in concert. And so that can be, there's a whole discussion just on that we could do that probably lasts an additional podcast. But then there's this new thing and the research that brought us to the discussion of chronic cough in the first place is looking at this new technique called superior laryngeal nerve blocks. And within laryngology, I think most people credit the initiation of this therapy to a paper that came out in 2018 by a guy named Blake Simpson, who at that point was working in Texas. Now he's in Alabama, and he did these nerve blocks, which he borrowed the technique from our pain management colleagues on people who had chronic refractory cough and had no relief with other therapy techniques and found that some people got better. And so he published this paper.

Paul Bryson: I wanted to also say another of our colleagues at Cleveland Clinic Florida, Dr. Laura Dominguez, I think was on that initial work as well. So I wanted to make sure we gave a little plug in recognition to Dr. Dominguez in Florida.

William Tierney: Oh yeah. And I didn't mean to leave her off, but the research into this is relatively new. So Dr. Dominguez, Dr. Simpson put this out in 2018, and then people start doing it and see, hey, we actually are getting results on this. And so the Cleveland Clinic main campus picked it up pretty early and started doing this on patients who had failed other therapy in 2019. And then we just put out this paper in The Laryngoscoope where we pooled all of our results between the 2019 through 2021 patients, did 464 injections, and found that the majority of our patients, I think it was 62%, about plus or minus point something had a positive benefit from these injections. And so of those people, 51% felt like it was enough of an improvement that they wanted to continue doing the injections. So it's sort of a third treatment modality that offers this chance at benefit to a group of patients who don't improve with any of the other therapies that we expect to possibly work. And so it's really been a powerful tool in our quiver to add to this challenging problem.

Paul Bryson: And it can, really, the quality of life of patients with chronic cough can be very poor. There is so much social isolation and challenges that they experience. Just simple things that we take for granted, going to the grocery store or going to a place of worship, where chronic cough can really alienate people. And so really like you talk about having another option in the quiver, it's really key to try to have options for patients. And this seems to be a pretty decent one. How was it tolerated by patients? How any unexpected challenges that were noted by our group?

William Tierney: So most patients, and a little more information on our study, we're looking at bilateral injections, we're doing both sides, which was not how it was originally described, but in patients who don't have a sightedness to their cough who say, oh yeah, my cough comes from my left side, which is relatively uncommon in my experience. So if people have sort of a vague cough or say that it's coming from their throat, we've been doing these bilateral injections and found them to be efficacious. Now the safety is another important thing that this paper outlines. And we found that less than 2% of patients had complications. And we did have a couple of people who had three people who had issues. One person who had received a large number of these injections ended up with some perra, which is bruising that we think was probably related to the steroid. They recovered with no difficulty, but we did stop the injection protocol for that patient. And then two other patients who also had received a large number of injections ended up with some what we call skin fragility, where the skin was basically weakened by the chronic steroid exposure and then cessation of therapy ended up with complete resolution of that as well. So even our more major complications did not lead to another medical issue that we know of.

Paul Bryson: Yeah, no, it's good to note. And you worry, I don't know if the paper talked about it per se, but you worry about our patients with type two diabetes or glucose intolerance, renal insufficiency or adrenal suppression from steroids. Any comments or things that we could glean from the data with that group?

William Tierney: So we worry about that. So this injection is made up, it's two injections, one into each side of the neck. Each injection is two milliliters, so about a 15th of an ounce, and it's made up of a steroid on a vehicle. We usually use triamcinolone acetate and then either a local anesthetic such as lidocaine. And then sometimes we also, if people are bothered by the lidocaine, will also use just sterile saline or salt water. And so the standard is sort of steroid and lidocaine and the steroid component as with things like an injection for back pain is a fairly high dose of steroid that then releases over a course of about a week. And so we worry about people's blood pressure coming up a little, their blood sugar coming up a little. And then there are some other more rare steroid side effects that we haven't seen with this. But the patient groups that we need to be careful with are people with diabetes, people with high blood pressure, and then people who are on chronic steroid regimens for some other disease where the additional steroid may cause some risk of additional medical issues.

Paul Bryson: Thanks for explaining that. It looks like a pretty provocative option for patients that have this problem. How do you incorporate the findings of this into the current practices in managing refractory chronic cough? And I guess what advice or considerations would you give to our listeners who might be healthcare professionals who would be interested in trying to incorporate this into their practice or something like that?

William Tierney: Yeah, so it's been a game changer in my cough practice just that I'm able to offer this. We've had those other two options, but many people don't want to do neuromodulators because one of the common side effects is drowsiness, and that bothers a lot of people. There's also a “do not operate heavy machinery” warning on most of these drugs. And so people who say drive a truck or you have to worry about things like operating an automobile may not be interested in that. And if they aren't and didn't want to do therapy, we were kind of stuck before, but now we have this at least trial that we can give people, which is quick, and you can do it the same day you see them. That gets you some answers.

I will tell both our patients and other healthcare providers who are wondering if a superior laryngeal nerve block might be appropriate for a specific situation that I only jump to this after we've proven that the common causes of cough are not the source because you certainly don't want to mask something more sinister or another disease process, which is work. So most patients end up getting an evaluation with pulmonary. Some people also need to see a gastroenterologist. Everyone should be worked up by a generalist just to make sure we're not missing something obvious. And then the laryngology group or a comprehensive otolaryngologist needs to look for those things like nasal disease allergy. Sometimes there's a role for allergy testing as well, but all those boxes need to be checked before we jump to this procedural intervention.

Paul Bryson: I mean, it's a great point. You don't want to forego a chest x-ray or a CAT scan of the chest and the cough workup, or you don't want to forget about a blood pressure medicine that has a side effect of dry cough. So there's sometimes some things that, and I don't know about your practice, but sometimes in my practice, I still have my detective hat on a little bit and make sure that we haven't overlooked something more obvious.

William Tierney: And I think after you do this for a certain amount of time, I think we've all seen the patient who's presenting symptom of a lung cancer was a chronic cough. Those people are much more rare than chronic refractory cough in my practice, but I know a few. And so I think the medical workup remains critical. And honestly, one of the reasons I love my job is that I'm never complacent. You're always looking for the cause of something so that hopefully you can help people get better both in symptoms and then also in causes of disease.

Paul Bryson: So based on this research, what are some of the next steps in terms of future studies and clinical applications? I'll chime in first. I think one of the hard things and see what you think, but trying to figure out who's going to respond to what is really difficult. I think of it as like a cough phenotype, if you will. And I don't know that I have a bunch of cough phenotypes to decide who's going to respond to what. Sometimes I'm surprised at what people respond to.

William Tierney: And I totally agree with that. I think there's a space where coming up with algorithms that predict who should get what first, that's probably opening up now as we start to have these larger data sets with 500+ injections. But we're still kind of in the infancy of this technique, which again, the first publication 2018, it's amazing that we have the data we have right now, but I think it speaks to how common this problem is. So the next things that we have started experimenting with are just adding to our cough database to hopefully do some predictive statistics. And then we also have some patients who now that we're using this superior laryngeal nerve block technique on cough, there are some sort of related issues which we've applied it to. And we just published another paper on the non-cough applications of superior laryngeal nerve block where we've found that some patients with sort of cough adjacent issues like throat clearing and Globus sensation, which is lump in the throat feeling, may get better with it. And so expanding the indications and kind of figuring out where we can use it and what the stewardship of the technique is will be the challenge for the next five years of its existence.

Paul Bryson: Yeah, well said. I think exit strategy is a question that I get from patients I don't know, can we change our cadence of injection? How long and at what magnitude of cough control is acceptable to start deescalating care? Those are questions that I also have. And then maybe some new drugs on the horizon. Different mechanistic targets in the cough reflex will actually come to market, but are not there yet with the prevalence of this issue.

William Tierney: If there were to be a pharmacologic cure for chronic cough, it would be a blockbuster. And so there are a lot of people thinking about it, just knowing the basic science behind it. I'm hopeful, but I'm not going to hold my breath.

Paul Bryson: It's a pretty complex pathway.

William Tierney: It is.

Paul Bryson: Well, if a listener wants to refer a patient or themselves to one of our laryngologists, what can they expect when they come to our team for care? I think we kind of alluded to this a little bit, but what could you tell a referring provider?

William Tierney: Yeah. Well, so I think one of the things that we've implemented really well here in northeast Ohio is this is a team sport. And without a pulmonologist that works with you, a gastroenterologist that works with you, it's hard to do this. And so if someone were to refer to the Voice Center for it, they can expect either if they've already had all that workup done, we can often see people rule out a laryngology source of cough and then get a superior laryngeal nerve block done that day. But in a patient where it's still more exploratory, you can expect a robust kind of medical evaluation with probably some referrals and or testing to make sure that we're not missing something. Because again, this is something where you have to rule everything else out before you deem it to be refractory.

Paul Bryson: Yeah, I mean, I think that's well put, right? Just we have this tool. We don't want it to be a hammer in every cough be a nail. So we have to remain thoughtful like you had alluded to earlier,

William Tierney: And there is the temptation, because often I'm sure you've seen this in your practice, but I have a few patients who really stand out where I do this injection, they've been coughing for 10 or more years, and a week later I get a message that says, you're my favorite doctor. This. I've never not coughed. And so there's a temptation to apply it broadly because occasionally you really get a home run on it. You also have patients where it doesn't work. And so it is exploratory still, but it's been a game changer in our practice and definitely a good tool that we can add to the management of a tough problem.

Paul Bryson: Absolutely. Well, I wanted to change gears just a little bit. Since you're back on the podcast. I understand you have a new role with our Cleveland Clinic Alumni Association, and as an alum yourself, you offer and bring a great perspective on the journey through medical school and surgical training here. Anything you can share about our alumni association?

William Tierney: Yeah, so I appreciate the opportunity to do a short plug for something else, but I was recently elected to be the specialty director for Otolaryngology-Head and Neck Surgery for the Cleveland Clinic Alumni Association. And for our listeners, if anybody has trained or worked at the Cleveland Clinic, you may not know this, but you are eligible to be a member of the Cleveland Clinic Alumni Association, which has a bunch of different resources. Maybe the most important of which is that you have access to the alumni lists. If you ever need to find someone who has had great training or the experience of working at the Cleveland Clinic and you're trying to find someone, say in South Carolina or anywhere in the country that you can find some alumni, and there's a list of all of that that you can get access to. And if anybody's interested, you can go to cleveland clinic.org/alumni, and there are a few different tools that are available, including some registration information if you're an alumnus yourself and interested in joining that group of physicians.

Paul Bryson: Yeah. Well, thanks for that.

William Tierney: Yeah. As a now, thrice, I was a medical student, I guess a grad student and a resident here, so a triple alumnus. I feel strongly about the organization and think that it's a good group of services for people who have put time into caring for our patients.

Paul Bryson: Well, as we wrap up, any take home messages for our listeners? We covered a lot of ground today.

William Tierney: No, I mean, I think just remembering that there are options for these coughs and that it's not something that you just have to live with is important, and we're happy to help if we can.

Paul Bryson: Well, thanks for coming on today, Will. For more information on Laryngology at Cleveland Clinic, please visit ClevelandClinic.org/Laryngology. That's ClevelandClinic.org/Laryngology. And to connect directly with a specialist or to submit a referral, call 216.444.8500. That's 216.444.8500. Dr. Tierney, thanks for joining Head and Neck Innovations.

William Tierney: It's a pleasure as always, Paul.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.