Vocal Cord Dysfunction Presenting as “Steroid-Dependent” Asthma

Abstract

Objective: To describe a case of paroxysmal vocal cord dysfunction (PVCD) in a patient presenting with an initial diagnosis of severe asthma. Case Summary: A 42-year-old obese white woman with a 5-year history of severe asthma symptoms was referred to The Ohio State University Comprehensive Asthma Outpatient Clinic. The patient said she had experienced frequent “asthma attacks” despite increased use of multiple asthma medications. Additionally, she often required nebulization therapy with bronchodilators and supplemental oxygen, and had a variable response. During the clinic visit, the patient presented with clear airways uncharacteristic of a person with severe asthma. A diagnosis of PVCD was made on the basis of results of videolaryngostroboscopy, and asthma medications were gradually discontinued. Setting: The Ohio State University Comprehensive Asthma Outpatient Clinic. Discussion: Patients with PVCD often present with symptoms characteristic of asthma. As a result, misdiagnosis of severe asthma often occurs, and the patient undergoes unnecessary treatment. The cornerstone for diagnosis of PVCD is laryngoscopic viewing of the adducted vocal cord during an acute attack. Following diagnosis, treatment for PVCD includes a multidisciplinary approach that includes speech therapy and psychiatric counseling. Pharmacologic therapy in patients with pure PVCD is not required, thus preventing medication-related morbidity and associated costs. Conclusions: PVCD must be considered in patients who are refractory to asthma therapy and have dyspneic symptoms out of proportion to observed clinical findings. We suggest that all patients with episodes of acute asthma undergo objective testing to document acute airway obstruction. Oral corticosteroid therapy and treatment-associated morbidity can be avoided in patients with PVCD if the appropriate diagnosis is made early.