Vickie Harwood was sick of feeling like an outcast.
For nearly six months beginning last July, Harwood had been sequestered in an office by herself, far removed from the large room full of cubicles where her co-workers sat. Being alone in an office with a fan running and the door closed seemed to be the only way to quell her uncontrollable coughing fits triggered by perfume or other strong fragrances.
Harwood worried that some of her colleagues might be skeptical about what appeared to be a dramatic worsening of the adult-onset asthma with which she had been diagnosed 20 years earlier.
“I felt like the girl in the bubble,” said Harwood, 61, who lives in Phoenix. Because desk assignments at the giant consulting firm where she works as an administrative assistant are based on rank — private offices are reserved for senior managers — Harwood worried that her colleagues suspected she might be milking her illness to secure an office.
Several made it clear they were put off by the measures she took to avoid a coughing fit. “People would get offended if I had to stand away from them” while having a conversation, she recalled.
Although doctors initially assumed her asthma was to blame, Harwood would discover that her cough was caused by something else entirely. “Once you have a diagnosis in place, everyone just kind of rolls with that,” she said.
In 1994, Harwood, then living in the San Francisco area, began feeling winded when she spoke. Two decades earlier, Harwood, who took voice lessons and sang at weddings and in amateur musicals, had undergone surgery to remove benign polyps from her vocal cords after she strained her voice. Through vocal therapy sessions, she had learned proper technique and had avoided a recurrence. Her first thought was that new polyps had formed.
She saw a respiratory specialist, who performed a series of tests. The doctor told her that there was no sign of new polyps. “He said, ‘I really can’t figure out what’s wrong with you, so by process of elimination, we’ll call it asthma,’ ” she remembers the doctor telling her, although it wasn’t clear what was causing it. But the doctor seemed convinced, so she began using the asthma inhaler he prescribed.
Around the same time, Harwood faced an equally pressing problem: She had developed a hiatal hernia that was causing a severe form of heartburn known as gastroesophageal reflux disease, or GERD. The hernia, which can occur as a result of an anatomical defect, pregnancy or obesity, causes the stomach to slide up into the esophagus when a person swallows, resulting in burning pain in the chest.
To ease her symptoms, a gastroenterologist told Harwood to sleep on an incline, not flat on her back. He prescribed an acid-blocking drug that, at $300 per month and not covered by her insurance, Harwood took only sporadically.
For the next 20 years, she had few problems with either asthma or GERD.
But in the spring of 2014, her insurer informed her that it would no longer pay for her longtime asthma medicine. Her internist prescribed a different inhaler, which was covered under her plan.
A few weeks after she began taking the new drug, Harwood started coughing soon after she arrived at work. “It was like a continuous tickling in my throat,” she recalled.
After two hours, her lungs felt raw and Harwood was short of breath and exhausted. The problem recurred with increasing frequency, and Harwood suspected that the perfumed body lotion she wore was responsible.
She stopped wearing it but noticed that other fragrances had the same effect. Oddly, she didn’t cough much outside the office — unless she got a whiff of a strong scent.
Harwood also felt unusually fatigued. By lunchtime she felt so tired she could “barely put one foot in front of the other” and complete her 30-minute exercise walk. Her once-refreshing after-work swim became a slog.
The fatigue reminded Harwood of how she had felt in 2009 when she developed walking pneumonia, a milder form of the lung infection. Her internist at the time had chided her for not using her inhaler regularly, because asthma can worsen pneumonia. Harwood explained that she used it only sporadically because she couldn’t see that the drug was making a difference.
“The doctor told me that asthma was a chronic condition and that I was no spring chicken and therefore more susceptible to these respiratory illnesses,” she recalled. She began taking the medicine every day.
In late July, after several weeks of coughing, Harwood decamped to a spare office used by out-of-town employees. She kept the door closed and a fan running, and after a few days, felt much better. Perhaps, she thought, the new asthma drug was responsible for her sudden sensitivity to fragrances.
Harwood returned to the internist, who agreed that the medicine didn’t seem to be working. The doctor requested an exemption from Harwood’s insurer, which was quickly granted. She resumed taking her old asthma medicine, this time at a higher dose. “I thought, ‘Okay, now I’ll be fine.’ ”
She wasn’t. The coughing returned, and Harwood grew increasingly worried about keeping her job. “I knew I couldn’t stay in that office forever,” she said, “and I thought, ‘Oh my God, what am I going to do?’ ”
By this time, she had grown so sensitive to fragrances that her husband had to stop wearing deodorant or cologne. Once when he forgot, her coughing was so bad that the couple had to make the 50-minute drive to work with the car windows down, wilting in the triple-digit Arizona heat.
“This was really starting to bother me,” Harwood said. “How do you live in a world where fragrance is in everything?”
In late August, Harwood consulted an asthma specialist. After a battery of tests, the doctor told her he thought her cough was not being triggered by asthma but by GERD; asthma and GERD sometimes coexist, although doctors are unsure of the relationship between the two conditions. He recommended that she consult her gastroenterologist and faithfully take her acid-blocking drug, which was now cheaper and available over the counter.
A few weeks later and no better despite the acid blocker, Harwood was worried that she had damaged her lungs, so she decided to see a lung specialist before calling her gastroenterologist. She tried to explain to her co-workers that she was having “an asthma problem” that was proving hard to control.
On Nov. 18, she saw pulmonologist Elinor Schottstaedt, who zeroed in on the raspy quality of Harwood’s voice and asked her why she was repeatedly clearing her throat.
Harwood replied that someone on the bus she had taken to the doctor’s office had been wearing perfume, triggering her cough.
Schottstaedt said she was immediately suspicious when Harwood told her of the diagnosis of adult-onset asthma. “That’s atypical,” Schottstaedt said, “and when it occurs, I want an explanation for it. She has no allergies characteristic of asthma, nor did she have any wheezing.”
Harwood’s description of an instantaneous reaction to fragrances, the pulmonologist said, seemed less indicative of a lung problem like asthma than of a laryngospasm, a sudden, brief spasm affecting the vocal cords that makes it difficult to speak. The doctor noted Harwood’s long history of acid reflux and her complaints of fatigue when she awoke, neither of which typifies asthma.
Schottstaedt suspected that Harwood had a condition called vocal cord dysfunction (VCD), not asthma. The misdiagnosis is common; in fact, the two conditions can coexist, although in Harwood’s case they did not. There is no evidence that Harwood ever had asthma.
VCD occurs when the vocal cords do not open correctly because the vocal muscles tighten, making breathing difficult and causing a feeling of breathlessness. Coughing is a common symptom, and unlike people with asthma, which causes problems breathing out, VCD sufferers find it more difficult to breathe in. GERD can exacerbate or trigger VCD, as can inhaling smoke or strong odors including fragrances. Chronic cough and frequent throat clearing can further irritate the vocal cords.
The first description of VCD dates back to 1951, when it was dubbed “factitious asthma”; doctors essentially thought patients were lying.
Three decades later, a team of specialists at National Jewish Health in Denver outlined effective treatment, which includes controlling acid reflux. Speech therapy to relax the vocal muscles, and techniques to suppress coughing and to combat stress are often recommended. In some cases, several days of complete voice rest are required to allow the vocal cords to begin to heal.
To confirm her suspicion, Schottstaedt ordered a videostroboscopy, a test that uses rapid bursts of light to inspect the movement of the vocal cords. The test revealed that Harwood’s vocal cords were not functioning properly, confirming Schottstaedt’s diagnosis.
Schottstaedt also said she suspected that Harwood might have obstructive sleep apnea. Although Harwood is fit and not overweight — unlike many people with sleep apnea — she snored and her sleep was not restorative. Both are characteristic of sleep apnea, in which loud snoring is followed repeatedly by a brief cessation of breathing, causing a person to awaken repeatedly. The condition, which results when the muscles at the back of the throat relax improperly, is a risk factor for heart attack and stroke.
After testing revealed a mild case of sleep apnea, Harwood began using a portable device called a CPAP machine at home, which she said improved her sleep. She also began taking a stronger acid-blocking medication prescribed by her gastroenterologist, who advised her to reduce GERD by not eating for three hours before bedtime.
At Schottstaedt’s recommendation, Harwood also underwent several speech therapy sessions to help improve the functioning of her vocal cords.
The crucial test occurred in January after several weeks of treatment. Harwood returned from a two-week Christmas break and sat at her own cubicle for the first time in months, braced for what might happen.
“It went perfectly,” she said. Other than an occasional cough, Harwood said she feels fine. Her sensitivity to fragrances has diminished to the point that she can even wear perfume again, although she dabs it sparingly — on her ankles.
Harwood is grateful for Schottstaedt’s expertise and glad to be back with her co-workers. “The biggest thing that makes me angry is being told I had asthma and taking medicine I didn’t need for 20 years.”