19 Y/o Male Marine Experiencing Exercise-induced Laryngeal Obstruction (eilo) During Military Training.

Abstract

HISTORY: 19 year old male with a long history of shortness of breath on exertion. States that since childhood he has had inspiratory wheezing and tightness in chest with exertion, but he was told he would outgrow it. More recently, he has noted that it has worsened with maximal exertion during military training. He states that he is unable to run all out once around the track without experiencing inspiratory difficulty with gasping. It takes about 10 minutes for him to recover. If he resumes exercise it will recur. Asthma inhalers have not helped. Episodes are associated with pain and dysphagia. PHYSICAL EXAMINATION: Laryngeal examination shows that there is reduced abduction of the vocal folds, with a maximum glottic space of about 6 mm. During high ventilatory output tasks there is evidence of paradoxical movement of the vocal folds, most prominently on inspiration, resulting in shortness of breath, and loud stridor on inspiration. Cardiac: RRR, without murmur Lungs: Clear to Auscultation bilaterally"at rest", Loud inspiratory stridor during “high ventilation”.MSK: Significant muscle tension dyspnea, an inefficient breathing pattern with an upper torso / clavicular breathing, and hyperfunction of strap muscles. DIFFERENTIAL DIAGNOSIS:- Hypertrophic Obstructive Cardiomyopathy (HOCM)- Asthma- Exercise-Induced Bronchoconstricion (EIB)- Exercise-Induced Laryngeal Obstruction (EILO)- Exercise-Induced Anaphylaxis (EIA) TEST AND RESULTS: Cardiopulmonary Exercist Test (CPET): negative. Spirometry with methacholine challenge: negative. Laryngeal function Study: videoendoscopy with stroboscopy revealed reduced abduction of the vocal folds. During high ventilatory provocative challenge, there was evidence of paradoxical movement of the vocal folds, most prominently on inspiration, resulting in shortness of breath, and loud stridor on inspiration. FINAL/WORKING DIAGNOSIS: Exercise-Induced Laryngeal Obstruction (EILO) Patient has developed poor breathing patterns with reduced bilateral vocal fold abduction. TREATMENT AND OUTCOMES: Breathing Retraining Therapy (4-6 sessions). Patient report significant improvement in symptoms after 2nd session, and complete resolution of symptoms following the 5th session. Remaining symptom free for 4 months.