Paradoxical Vocal Cord Dysfunction Research Articles

Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial.

Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and β-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.

Exercise-induced laryngeal obstruction (EILO) in children and young adults: From referral to diagnosis.

To identify different presentations, referral patterns, comorbidities, and laryngoscopy findings in children and young adults with exercise-induced laryngeal obstruction (EILO). We performed a retrospective chart review of 112 patients, age <26 years, with EILO between 2013 and 2016. Of the 112 patients who met criteria, 91 were female and 21 were male. Patients were most frequently referred by pulmonologists (60.7%). The majority of patients (93%) participated in organized sports, most of them at a competitive level. The mean age at symptom onset was 13.8 ± 3.3 years, and the mean age of diagnosis was 15.4 ± 3.0 years. Sixty-seven (59.8%) patients presented with a prior diagnosis of asthma, the majority of whom had failed asthma treatment. The most common symptoms reported were dyspnea (93.8%), wheezing/stridor (78.6%), and throat tightness (48.2%). Ninety-one (81.3%) patients had spirometry performed, with 46 (51.1%) showing inspiratory loop flattening. On flexible laryngoscopy, 87 (78.4%) of 111 patients had paradoxical vocal fold motion. Supraglottic involvement was observed to obstruct the airway in 26 (23.9%) patients, with patterns of obstruction similar to those observed in children with laryngomalacia. Most patients participated in competitive sports, were female, and presented with exertional dyspnea. Most patients were diagnosed with exercise-induced asthma but treated unsuccessfully. Almost one-quarter of our patients showed supraglottic collapse obstructing the airway. Exercise-induced laryngeal obstruction is a more descriptive term than paradoxical vocal fold motion or vocal cord dysfunction, which only describe vocal fold involvement. The time to diagnosis of EILO was shorter than previously reported, suggesting that awareness of this condition is increasing. 4 Laryngoscope, 130:E400-E406, 2020.

SUCCESS RATE OF TRACHEOBRONCHOPLASTY FOR TRACHEOBRONCHOMALACIA AND EXCESSIVE DYNAMIC AIRWAY COLLAPSE AFTER A POSITIVE STENT TRIAL

SESSION TITLE: Interventional Pulmonary SESSION TYPE: Original Investigations PRESENTED ON: 10/08/2018 04:30 PM - 05:30 PM PURPOSE: Tracheobronchoplasty in experienced hands has been shown to improve respiratory symptoms, quality of life and functional status in patients with severe symptomatic tracheobronchomalacia (TBM), or excessive dynamic airway collapse (EDAC)(1). Before surgery, patients undergo a stent trial to determine symptomatic and physiologic (FEV1 and 6 minute walk test (6MWT)) improvement in an effort to mimic therapeutic conditions with tracheobronchoplasty(TBP); if symptoms and objective measurements improve they are considered to have a positive stent trial and candidates for TBP. The aim of this study was to determine the success rate of patients who underwent TBP after stent trial and determine possible factors of TBP failure. METHODS: This was a retrospective study of prospectively collected patients with severe TBM and EDAC who underwent TBP between (2014-2018). We defined TBP success with the following scoring system: 1) improvement of 2/3 symptoms (cough, shortness of breath and ability to clear secretions), 2) improvement in 2/3 questionnaires (MMRC dyspnea scale, CQLQ score, SGRQ quality of life measure) and 3) improvement in FEV1 or 6 MWT. If 2 items were positive, it was considered as a successful surgery at the 3 month follow up RESULTS: Thirty one patients (median age 55.1 (±11.3), 87.1% (n=27 females) were treated with TBP, (64.5%, n=20) were diagnosed with TBM and (35.4%, n=11) with EDAC, all of them underwent stent trial previous to surgery. Relevant comorbidities were gastroesophageal reflux (74.1%, n=23), asthma (45.1%, n=14), obstructive sleep apnea (35.3%, n=11), paradoxical vocal cord dysfunction (22.5%, n=7) and chronic obstructive pulmonary disease (16.1%, n=5). After TBP there was a reduction of symptoms from (100%, n=31) to (84%, n=26) (p:0.00), MMRC dyspnea scale from 3 (IQR 2-3) to 1 (IQR 0-2) (p:0.001), of CQLQ scale from 72 (±15.0) to 56 (±16.6) (p:0.001), of FEV1% from 72.8 (±21.2) to 73 (±18.2), (p:0.9) and 6MWT increased from (1063.9ft, ±309) to (1240.3ft ±371) (p:0.01). (90% n= 28) Patients meet criteria for successful TBP vs (9.6%,n=3) who didn’t. The reasons for failure were high functional status, atypical baseline symptoms, concentric TBM, and untreated comorbidities after surgery such as COPD. CONCLUSIONS: Tracheobronchoplasty results in symptom improvement in the majority of patients with TBM and EDAC after a successful stent trial. Untreated comorbidities such as severe COPD, atypical presenting symptoms, and concentric morphology may predict failure. CLINICAL IMPLICATIONS: Tracheobronchoplasty have symptom improvement in the majority of patients with TBM and EDAC after a successful stent trial. Untreated comorbidities such as severe COPD, atypical presenting symptoms, and concentric morphology may predict failure. DISCLOSURES: No relevant relationships by Daniel Alape-Moya, source=Web Response Consultant relationship with Boston Scientific Please note: $1-$1000 Added 03/02/2018 by Alex Chee, source=Web Response, value=Consulting fee No relevant relationships by Sidhu Gangadharan, source=Web Response No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $5001 - $20000 Added 03/04/2018 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with Olympus Please note: $5001 - $20000 Added 03/04/2018 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Mihir Parikh, source=Web Response No relevant relationships by Melibea Sierra, source=Web Response no disclosure on file for Jennifer Wilson

The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction

Exercise-induced laryngeal obstruction (EILO), the condition previously known as paradoxical vocal fold motion and vocal cord dysfunction, is characterized by inappropriate glottic or supraglottic obstruction during high-intensity exercise, causing exertional dyspnea, frequently with stridor. EILO is definitively diagnosed through upper-airway visualization during a characteristic episode. Although respiratory retraining is a primary therapy for EILO, many patients report symptom persistence despite adequate performance of traditional techniques. This report describes three novel breathing techniques for EILO, the Olin EILOBI (EILO biphasic inspiratory) breathing techniques. We include a teaching process and case series with patient-reported assessments. Following descriptions of the techniques and teaching process, we present data from a questionnaire offered to all patients who learned at least one of the techniques between September 2015 and March 2017. Subjects evaluated (1) expectation setting, (2) teaching processes, (3) their ability to implement the techniques during high-intensity exercise, and (4) perceived clinical effectiveness. Ninety-five percent of eligible patients participated, a primarily young, female, and Caucasian sample. Over 50% of subjects competed at the high school varsity level. Sixty-two percent of subjects perceived reasonable expectations, and 82% positively evaluated the teaching process. Seventy-nine percent were able to employ their technique in the high-intensity activity of choice, and 66% perceived clinical effectiveness with the techniques. The Olin EILOBI breathing techniques are novel respiratory retraining techniques for use in high-intensity exercise. Case series subjects reported reasonable expectations, a helpful teaching process, the ability to use these techniques during high-intensity exercise, and perceived clinical effectiveness.

Asthma and comorbidities

This article summarizes the more common comorbidities which, in the opinion of the authors and supported by the medical literature, frequently affect asthma management. Optimal asthma control requires accurate diagnosis, implementation of effective therapy, and evaluation of coexisting conditions. Comorbidities refer to either coexisting conditions or interacting conditions, with the latter having a more significant influence on the management of asthma. This review provides the authors' clinical perspective of the more common comorbidities and relevant literature reviewed primarily from the past 4-5 years. Optimizing rhinitis and rhinosinusitis management and addressing allergic sensitivity and allergen exposure are achievable measures for the most common asthma comorbidity. Psychological dysfunction and paradoxical vocal cord dysfunction are frequently associated with poor asthma control. The effects of obesity are inconsistent in the literature but obesity likely affects asthma symptoms and possibly its pathogenesis. Treatment of asymptomatic gastroesophageal reflux does not improve asthma. Asthma is a common disease and other conditions frequently occur concomitantly in individuals with asthma. Asthma is usually very treatable and comorbidities should be considered and addressed or the asthma diagnosis questioned if treatment effects are not optimal. Evidence-based medicine is lacking as most asthma studies exclude comorbidities; additional studies are needed.

Laryngomalacia in the Setting of Vocal Cord Dysfunction

Objective: To describe the management and outcome of patients with clinically significant laryngomalacia (LM) and simultaneous vocal cord dysfunction (VCD). Methods: Children with LM and VCD treated at our tertiary referral center from 2003-2009 were reviewed retrospectively. Main outcome measures include resolution of VCD, polysomnography (PSG) parameter changes, and changes in breathing and swallowing after treatment. Results: Seven children were reviewed. Six patients had bilateral paresis and one patient had a paradoxical VCD. A third airway lesion was found in two patients. All patients were treated with reflux therapy. Five patients were treated with supraglottoplasty (SGP), and the patient with paradoxical VCD was treated with Botox injections. Two of the three patients with PSG studies preand post-SGP showed improvement in AHI and O2 nadir. The third patient had improved PSG parameters after an adenotonsillectomy. While breathing did improve in six patients, two patients required a tracheostomy for aspiration. Both patients treated without SGP and one patient treated with SGP required a percutaneous gastrostomy tube. Six (86%) patients were ultimately swallowing without aspiration (mean 11.4 months). VCD resolved completely in three patients, all of whom underwent SGP. Conclusion: The two most common causes of stridor in infants can occur simultaneously. While the management is often multifactorial, early SGP may improve airway obstruction without increasing the risk of aspiration in these patients. While breathing ultimately improved after primary treatment in all patients with vocal cord paresis, the patient with paradoxical VCD required a tracheostomy for ongoing airway obstruction after failing Botox injections. Four patients treated with SGP required additional surgeries: one child required a tracheotomy for respiratory distress and was decannulated within a year; another patient required a single-staged laryngotracheal reconstruction for subglottic stenosis; a third patient required an adenotonsillectomy; and a final patient required a gastrostomy tube for FTT. Of the three patients who underwent PSG preand post-SGP, two showed considerable improvement in AHI and O2 nadir. The third patient’s PSG parameters worsened postoperatively, which were thought to be due to adenotonsillar hypertrophy and obstruction. The patient’s PSG improved after an adenotonsillectomy. One patient who did not undergo SGP had more mild obstructive symptoms. Her gastroesophageal reflux was severe enough, however, to require a Nissen fundoplication and gastostomy tube.

Respiratory muscle strength training applications

To provide an overview of respiratory muscle strength training applications for voice and speech disorders. Little examination of respiratory muscle training for the rehabilitation of voice and speech has occurred. Less than a handful of studies discuss use of strengthening techniques for the voice-disordered population and of those, inspiratory muscle strength training shows promise for use with upper airway disorders including abductor vocal fold paralysis and paradoxical vocal cord dysfunction. Case study results of Lance Adams syndrome indicated a positive outcome for maximum phonation time and improved intelligibility ratings and communication effectiveness. Work with the multiple sclerosis population showed no change in qualitative ratings of patient voice handicap and no significant improvement in speech production variables. Current trials with Parkinson's disease are ongoing with no published data currently available with regard to voice and speech production. Respiratory muscle strengthening programs are either inspiratory or expiratory and are typically accomplished using handheld devices. Training durations typically examined have been 4-8 weeks. Training trials usually take 20-30 min per day. Training frequency varies across studies. Detraining outcomes are important to examine as part of clinical trials. Defining detraining outcomes has major implications for the development of a complete rehabilitation program.

Sniffs, Gasps, and Coughs

Sniffs, Gasps, and Coughs

THE USE OF SPIROMETRY AND IMPULSE OSCILLOMETRY IN THE DIAGNOSIS OF VOCAL CORD DYSFUNCTION IN THE PEDIATRIC PATIENT

PURPOSE: The diagnosis of paradoxical vocal cord dysfunction is suggested by the patient's clinical history. It is definitively made by observing the vocal cords via flexible laryngoscopy/bronchoscopy. Paradoxical vocl cord dysfunction can also be suggested by a flat inspiratory limb of the spirometry flow-volume loop. An increase in airway resistance via impulse oscillometry may also suggest paradoxical vocal cord dysfunction. The purpose of this study was to evaluate the usefulness of spirometry and impulse oscillometry in the diagnosis of pardoxical vocal cord dysfunction.

Characteristics of Pediatric Patients with Paradoxical Vocal Cord Dysfunction that Present with Complaints of Wheezing or Shortness of Breath

PURPOSE: Patients with paradoxical vocal cord dysfunction(PVCD) frequently present with complaints of wheezing or shortness of breath(SOB) and are frequently diagnosed with asthma and treated unnecessarily for asthma. Our study examines patients referred to a Pediatric Pulmonary Clinic for uncontrolled asthma or SOB who were diagnosed with PVCD.

Physical symptoms in sexually abused women: somatization or undetected injury?

AbstractMedically unexplained physical symptoms and disorders in women sexually abused in childhood are widely interpreted as somatization—the expression of emotional pain and stress through bodily symptoms. However, the somatization theory is not based on detailed knowledge of the abusive incidents, and may underestimate the direct effects of violence and injury, repeated over years, to children's developing bodies. When adult survivors fully describe their childhood abuse, the extent of violence involved becomes clear. For example, their accounts of oral abuse invite us to reconsider how ‘psychogenic’ conditions like paradoxical vocal cord dysfunction or temporomandibular disorders may have come about. This also raises the important issue of whether paradoxical vocal chord dysfunction should be reclassed as an abnormal and suspicious sign in children. The paper outlines several forms of research which may elucidate further the role of physical damage and injury in adult survivors' physical disorders, including prospective studies; retrospective studies in collaboration with sexual abuse survivors; and comparative studies of international literature on the long‐term physical health effects of torture and child marriage. Copyright © 2002 John Wiley &amp; Sons, Ltd.

Dysfonction laryngée épisodique

Episodic laryngeal dysfunction (ELD), also known as paradoxical vocal cord dysfunction or laryngeal dyskinesia, is characterized by abnormal closure of the vocal cords during inspiration (and sometimes at the very start of expiration). It can manifest in different ways depending on the patient's age. In the newborn, it is usually associated with stridor restricted to the inspiratory breath following crying, and the natural history is always one of rapid resolution. Occasionally, a more severe form presents with intense dyspnea and marked inspiratory stridor in a baby that usually has extensive gastroesophageal reflux which has not been treated adequately enough to improve the dyspnea or the associated vasovagal attacks. A tracheotomy may be necessary. It is rare for this disease to present between the ages of 2 and 8 years. Thereafter, it may present as a form of pseudo asthma resistant to bronchodilators and anti-inflammatory drugs. The dyspnea can be very severe and lead the family to seek hospital admission, at least during the initial episodes. There is a female preponderance. The key to making the diagnosis is the complete reversibility of the patient's symptoms when they are distracted. Exertion asthma can be mimicked by forms of ELD that occur only by effort (apart from the profile of the lung function tests). There may be significant gastroesophageal reflux. Medical intervention (hospitalization and tracheotomy) must be avoided, treatment being essentially behavioral. Finally, some cases of paradoxical adduction of the vocal cords have been described with the use of neuroleptics, brain stem compression, cortical lesions and, much more rarely, motoneuron disease. This diagnosis requires a high index of suspicion, particularly in patients with asthma whose presentation or clinical course with treatment is atypical.

Paradoxical vocal cord dysfunction in juveniles.

To evaluate demographic and videolaryngoscopic features in a large series of juveniles with paradoxical vocal cord dysfunction (PVCD). Case series data from videolaryngoscopic tapes retrospectively evaluated in a masked, controlled fashion, and demographic data collected via retrospective medical chart review. A tertiary care otolaryngology and speech pathology referral center. Twenty-two patients with PVCD aged 18 years and younger diagnosed as having PVCD at The Ohio State University Voice Institute, Columbus. Age, sex, social history, and medical history (demographic); epiglottic position, arytenoid and interarytenoid appearance, phase 0 stability, true vocal cord respiratory motion, degree of anteroposterior (AP) constriction, and false vocal cord adduction (videolaryngoscopic). Of 22 patients, 18 were girls, and 12 had significant social stressors, particularly organized sports. Nineteen patients had posterior laryngeal changes commonly found in gastroesophageal reflux disease. Twelve patients demonstrated abnormal true vocal cord adduction during quiet respiration. Seven patients demonstrated supraglottic anteroposterior constriction and false vocal cord approximation during phonation. Juvenile PVCD is more common in girls and is associatedwith social stresses. Anatomic laryngeal changes typically associated with gastroesophageal reflux disease are extremely common in these patients. Juveniles with PVCD frequently demonstrate abnormal true vocal cord adduction during quiet respiration. We recommend that initial evaluation of juvenile patients for possible PVCD be conducted via transnasal fiberoptic laryngoscopy while the patient is asymptomatic, and that strong consideration be given to empiric pharmacological treatment of gastroesophageal reflux disease in juveniles diagnosed as having PVCD.

Psychogenic Respiratory Distress: A Case of Paradoxical Vocal Cord Dysfunction and Literature Review.

BACKGROUND: Pulmonary disease such as asthma is a psychosomatic disorder vulnerable to exacerbations precipitated by psychological factors. A case is described in which a patient thought to have treatment-refractory asthma was discovered to have a conversion reaction, specifically paradoxical vocal cord dysfunction (PVCD), characterized by abnormal vocal cord adduction during inspiration. DATA SOURCES: Reports of PVCD were located using a MEDLINE search and review of bibliographies. MEDLINE (English language only) was searched from 1966 through December 1998 using the terms functional asthma, functional upper airway obstruction, laryngeal diseases, Munchausen's stridor, paradoxical vocal cord dysfunction, psychogenic stridor, respiratory stridor, vocal cord dysfunction, and vocal cord paralysis. A total of 170 cases of PVCD were reviewed. STUDY FINDINGS: PVCD appears to be significantly more common among females. PVCD spans all age groups, including pediatric, adolescent, and adult patients. PVCD was most often misdiagnosed as asthma or upper airway disease. Because patients present with atypical and/or refractory symptoms, several diagnostic tests are employed to evaluate patients with PVCD; laryngoscopy is the most common. Direct visualization of abnormal vocal cord movement is the most definitive means of establishing the diagnosis of PVCD. A number of psychiatric disturbances are related to PVCD, including conversion and anxiety disorders. PVCD is associated with severe psychosocial stress and difficulties with modulation of intense emotional states. CONCLUSIONS: Psychogenic respiratory distress produced by PVCD can be easily misdiagnosed as severe or refractory asthma or other pulmonary disease states. Recognition of PVCD is important to avoid unnecessary medications and invasive treatments. Primary care physicians can detect cases of PVCD by attending to clinical symptoms, implementing appropriate laboratory investigations, and examining the psychological covariates of the disorder. Psychotherapy and speech therapy are effective in treating most cases of PVCD.

Paradoxical Vocal Cord Dysfunction Among Juveniles

Paradoxical Vocal Cord Dysfunction Among Juveniles

Paradoxical vocal cord dysfunction in an infant with stridor and gastroesophageal reflux

This article presents the case history of a 4 month old infant diagnosed with Paradoxical Vocal Cord Dysfunction (PVCD) secondary to gastroesophageal reflux. The child presented with intermittent stridor which responded promptly to treatment of her reflux. This is believed to be the youngest person with PVCD reported in the literature and supports the concept that PVCD may be associated with multiple etiologies.

Childhood Sexual Abuse in Patients with Paradoxical Vocal Cord Dysfunction

We present three prototypical cases of paradoxical vocal cord dysfunction. The symptoms of this functional disorder mimic those of bronchial asthma attacks. These patients typically have experienced extensive medical intervention including intubation and corticosteroid use. We identify a history of childhood sexual abuse as an important factor contributing to the development of this psychosomatic disorder. We discuss the severity of psychopathology in patients with paradoxical vocal cord dysfunction and how this physical symptom may have developed to express psychological difficulties.