Dynamic tonsillar prolapse masquerading as paradoxical vocal fold movement dysfunction

Abstract

IntroductionParadoxical vocal fold movement dysfunction (PVFMD) is a disorder in which the vocal folds involuntarily adduct during inspiration resulting in stridor, cough, dysphonia and dyspnea. Diagnosis of PVFMD is difficult given the episodic nature of the disorder and the often-normal laryngeal exam in between episodes. Moreover, additional sources of obstruction have been identified as sources of Periodic Occurrence of Laryngeal Obstruction (POLO). Treatments can vary with site of obstruction. ObjectiveTo evaluate pediatric patients presenting to a Vocal Fold Dysfunction Center for evaluation of exertional, inspiratory, harsh breath sounds and dyspnea suggestive of PVFMD whom were found to have a dynamic obstruction of the upper airway due to adenotonsillar hypertrophy and prolapse. MethodsRetrospective chart review of patients diagnosed with exertional dynamic tonsillar prolapse whom have undergone adenotonsillectomy. Clinical characteristics, spirometry, exam findings and response to adenotonsillectomy were recorded. ResultsSeven patients with exercise induced dyspnea and respiratory distress with whom underwent exercise spirometry then subsequent adenotonsillectomy were identified. Symptomatic co-morbidities were common and included: rhinitis (43%), reflux (29%), sleep disordered breathing (29%), asthma (14%), obesity (14%), prematurity (14%) and anxiety/post-traumatic stress disorder (PTSD) (14%). Preoperative use of bronchodilators or reflux medications was common. All patients were noted to have >50% oropharyngeal obstruction secondary to tonsillar hypertrophy and dynamic lateral pharyngeal collapse or tonsillar prolapse with inspiration. No exercise induced paradoxical vocal fold dysfunction was identified. All baseline and most exertion FVC, FEV1, FEV1/FVC and FEF 25–75% were normal. Four patients had flow volume loops suggestive of obstruction. All patients had symptomatic improvement after adenotonsillectomy. ConclusionsDynamic tonsillar prolapse can result in subjective exertional dyspnea and objective upper airway resistance mimicking PVFMD and treatment with adenotonsillectomy can greatly reduce symptoms.