Paradoxical Vocal Fold Motion Research Articles

Is trans-laryngeal ultrasound (TLUS) an accurate and acceptable tool in the assessment of inducible laryngeal obstruction? A protocol for the ILOTUS: A cross-sectional, two-stage feasibility study

BACKGROUND: Inducible laryngeal obstruction (ILO) describes an inappropriate narrowing of the larynx during breathing in. ILO can lead to several respiratory symptoms and be misidentified and treated as asthma, with associated patient morbidity and healthcare cost. ILO is also known as vocal cord dysfunction, or paradoxical vocal fold movement. The current reference assessment tool for diagnosing ILO is a video-laryngoscopy. However, timely access to specialist diagnostic laryngoscopy services may be challenging, and laryngoscopy may be poorly tolerated. AIMS: The aim of this cross-sectional, two-stage feasibility study is to determine whether abnormal vocal fold movements associated with ILO can be adequately visualised using trans-laryngeal ultrasound (TLUS) namely, the ILOTUS study: (ILO assessment via trans- laryngeal ultrasound). The second aim is to compare TLUS with a reference standard diagnostic tool to ascertain whether it may serve as a less invasive screening tool to assess ILO. Participants’ opinions about the acceptability of TLUS will also be gathered and compared with responses to a validated symptom score questionnaire. METHODS: In stage one, healthy volunteers (n = 30) will undergo TLUS to assess whether the vocal folds can be visualised,and whether narrowing of the vocal folds can be seen when they mimic ILO. Stage 2 will be conducted with a patient population(n = 30) referred to a tertiary airways service for breathlessness assessment. Participants in stage 2 will undergo the reference standard laryngoscopy as well as simultaneous TLUS. The level of agreement between TLUS and laryngoscopy will be evaluated, as well as comparison of symptom scores. DISCUSSION: This study will help inform future studies of the utility of TLUS in the assessment of ILO. This will be valuable for understanding whether TLUS could be offered as a non-invasive option for patients in the assessment of ILO if they are not able to tolerate or access laryngoscopy diagnostic services. It is not intended that TLUS will replace the current reference standard of video-laryngoscopy but may have potential as an early screening tool if found to be non-inferior.

Protocol for a scoping review to map health outcomes in individuals with inducible laryngeal obstruction.

Inducible laryngeal obstruction causes narrowing of the laryngeal aperture in response to external triggers. Outcomes are measured in inducible laryngeal obstruction to monitor changes in health status over time. This study is a scoping review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The review will be guided by the following research question: 'What health outcomes are measured in studies including people with inducible laryngeal obstruction?' The research question was validated using the Population-Concept-Context framework according to the methodology for Joanna Briggs Institution Scoping Reviews. Relevant peer-reviewed studies and grey literature conducted over the last 40 years will be identified from electronic databases including AMED, CINAHL, Embase, EMCARE, MEDLINE, OVID, PubMed and PsycINFO. The search strings 'inducible laryngeal obstruction', 'ILO', 'vocal cord dysfunction', 'VCD', 'paradoxical vocal fold motion', 'PVFM', 'outcome', 'measure', 'measurement instrument', 'assessment', 'scale', 'questionnaire' will be combined using Boolean logic. An independent reviewer will conduct title screening; two independent reviewers will conduct abstract and full article screening, followed by data extraction by two reviewers. Analyses will be conducted appropriate to the findings. The review will document evidence of health outcomes measured in inducible laryngeal obstruction, identifying measurement characteristics and potential utility. Collating studies may identify gaps in coverage, the need for novel tools, and for standardisation for clinical and research purposes. What is already known on the subject Inducible laryngeal obstruction causes narrowing of the laryngeal aperture in response to external triggers. Outcomes are measured in inducible laryngeal obstruction to monitor changes in health status over time. Currently, there are no standardised outcome measures for measuring the effects of interventions in inducible laryngeal obstruction (ILO). What this paper adds to existing knowledge Assessment of health can be measured in a variety of ways. Physiological, radiological and biochemical measurements of impairment are more common historically but there are a lot of outcomes of other factors now including subjective measures of functional status and health-related quality of life, with data collected directly from patients. This study will allow us to scope the literature to see the health outcomes being measured in ILO to attempt to standardise and develop future health outcomes. What are the potential or actual clinical implications of this work? The review will document evidence of health outcomes measured in inducible laryngeal obstruction, identifying measurement characteristics and potential utility. Collating studies may identify gaps in coverage, the need for novel tools and for standardisation for clinical and research purposes.

Variability of Maximum Glottal Angle on Clinical Sniff Task Differs in Patients With Functional and Organic Laryngeal Pathologies Compared to Healthy Controls

ObjectivesPractitioners rely heavily on flexible endoscopic visualization of the true vocal folds during a repeated “sniff-ee” maneuver to assess vocal fold mobility. However, the human eye lacks the temporal and spatial precision required to accurately gauge fine differences in maximal glottal angle. This study compared differences in maximal glottal angle variables during “sniff-ee” maneuvers across patients with various voice and laryngeal breathing disorders. MethodsWe retrospectively measured glottal angle from flexible laryngoscopy exams in six groups of patients with voice and upper airway disorders: laryngeal dystonia/essential tremor (LD/ET), vocal fold lesions, vocal fold atrophy, paradoxical vocal fold motion disorder (PVFMD), muscle tension dysphonia (MTD), and healthy controls. Maximum glottal angle (GAMAX) and average glottal angle (GAAVG) were calculated during three serial “sniff-ee” maneuvers for all participants. Individual disorder groups (MTD, PVFMD, LD/ET, atrophy, lesion) and broader disorder types (functional and organic) were compared to healthy controls using simple linear regression analyses. ResultsNo significant difference in either GAMAX or GAAVG was found between controls and the disorder subgroups or broader disorder type (function and organic). However, there were statistically significant differences in the variability of GAMAX in both PVFMD (6.2° more variability; p<0.001) and LD/ET (5.8° more variability; p<0.001) compared to healthy controls. ConclusionPatients diagnosed with LD/ET and PVFMD both demonstrated significantly more variability in their GAMAX compared to healthy controls, suggesting that movement consistency or coordination may be relatively compromised in these patient groups. Further research is warranted to investigate the sensitivity and specificity of glottal angle variability in diagnosing PVFMD and LD in clinical or research settings. Level of Evidence4 Short SummaryLaryngeal exams from five patient groups were compared to those from healthy controls. Patients with paradoxical vocal fold motion disorder and laryngeal movement disorders exhibited significantly greater variability of glottal angle during sniff maneuver compared to healthy controls.

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.

Clinical presentation of paradoxical vocal fold motion or laryngeal dyskinesia in infants.

Paradoxical vocal fold motion (PVFM) is not well-characterized in infants. Sex- and race/ethnicity-based differences have been described in older children with PVFM. This study's objectives are to characterize demographic and clinical characteristics of infants diagnosed with PVFM and investigate sex- and race-specific differences in presentation. We retrospectively reviewed infants ≤1 year of age diagnosed with PVFM at our institution from 2009 to 2019. Patient demographics, symptoms, and findings on flexible laryngoscopy are described. Sex- and race/ethnicity-based differences were assessed using Fisher's exact test analyses. We identified 22 infants who were diagnosed with PVFM. The average age (range) at diagnosis was 5.7 (0.25-12.0) months, and 45.5% were male. The majority (54.6%) of patients identified as non-Hispanic White. Common comorbidities included GERD (45.5%) and chronic rhinitis (13.6%). Stridor was the only presenting symptom in the majority of patients (95.4%). The most common episode triggers were crying (45.5%), feeding (27.3%), and gastric reflux (9.1%). On flexible laryngoscopy, PVFM was observed in 95.5% of patients. A third of patients (31.8%) were misdiagnosed as having reactive airway disease or laryngomalacia prior to evaluation by otolaryngology. No sex- and race/ethnicity-based differences in presentation were identified. We present the largest case series of PVFM in infants. We found sparse clinical signs/symptoms other than stridor and a high incidence of misdiagnosis, which supports the importance of objective flexible laryngoscopy for the evaluation of stridor in this age group. Previously reported sex- and race/ethnicity-based differences in presentation of PVFM were not observed in this cohort of infants.

The impact of a fast-track questionnaire in pediatric paradoxical vocal fold motion disorder (PVFMD)

PVFMD is a frequent cause of dyspnea in the healthy adolescent. When PVFMD is suspected, the current standard of care includes referral to an otolaryngologist (ENT) prior to beginning laryngeal control therapy (LCT) with a speech language pathologist (SLP). We hypothesize that a "fast-track" screening questionnaire will improve time to treatment and decrease patient charges. Patients (n=258, group 1) who received traditional referral and were evaluated in pediatric voice clinic with a diagnosis of PVFMD between 11/2013 and 11/2017 were identified and compared with 66 patients (group 2) from 10/2018 to 11/2019 who were prospectively studied and placed into a fast-tracked subgroup for LCT without preceding ENT evaluation if they scored 8/10 or higher on a designed screening questionnaire. Female gender (group 1: 81%, group 2: 83%, p=0.73) and median age (group 1:14 years IQR 4; group 2:14 years IQR 3, p=0.83) were similar. The median duration from symptom onset to LCT was shorter for group 2 (group 1: 12 months, IQR 18; group 2: 8.5 months, IQR 8)(p=0.02). Time from referral to LCT was shorter for group 2at 3 weeks (IQR 3) compared to group 1at 4 weeks (IQR 3.5, p<0.01). The minimum single patient charge for group 1 was estimated at $5123 and $1649 for group 2, yielding a potential reduction of charges of over $3000. Using a fast-track screening questionnaire for pediatric PVFMD patients significantly decreases the time to treatment without altering the response rate of LCT.

Repetitive Transcranial Magnetic Stimulation, a Novel Therapeutic Strategy for Refractory Paradoxical Vocal Fold Motion Disorder.

Paradoxical vocal fold motion disorder (PVFMD) is a condition involving the inappropriate narrowing of the larynx with symptoms of laryngeal tightness and dyspnea. A 23-year-old woman was diagnosed with PVFMD by imaging, revealing dynamically constricted, supraglottic tissue, an abnormal adduction of the vocal cords with a characteristic "posterior chink" observed. After diagnosis, laryngeal control retraining protocols and biofeedback therapy were initiated. To treat persistent symptoms, interventions such as vocal fold botulinum toxin (BoNT) injections were performed with slight improvements. Ultimately, psychiatry performed 10 repetitive transcranial magnetic stimulations (rTMS) with a right-sided, low-frequency approach to treat the patient's underlying major depressive disorder and comorbid anxious distress. Afterward, the patient's symptoms were successfully reduced with an improvement in Dyspnea Severity Index. Although most patients with PVFMD were relieved with laryngeal control therapy, some are refractory and lack the literature on the best treatment. In this case, we followed the multidisciplinary approach and individualized our novel therapeutic strategies including especially rTMS, which successfully reduced symptoms. This is the first reported case of refractory PVFMD to be treated with novel interventions, and rTMS might play a role in PVFMD mitigation.

Endoscopic aspects and associated factors in paradoxical vocal fold movement

IntroductionParadoxical vocal fold movement (PVFM) is a respiratory disorder related to inadequate movement of vocal folds during inspiration or expiration. Its epidemiology and pathogenesis are unknown. The present study describes the standardization of the examination performed in our service and the main endoscopic changes found, evaluating the prevalence of PVFM in patients with suggestive symptoms and describing the association of PVFM with asthma and other diseases. Materials and methodsRetrospective observational study of a series of cases over a 13-year period – adult patients referred for outpatient bronchoscopy due to suspected PVFM. ResultsWe analyzed 1131 laryngoscopies performed on patients referred for suspicion of PVFM from May 2006 to June 2019. Of these, 368 cases were excluded from the study. A total of 255 patients (33%) had a confirmed diagnosis of PVFM, 224 women (88%). The most frequent comorbidities found were asthma (62%), rhinitis (45%), gastro-oesophageal reflux disease (45%), obesity (24%), and psychiatric disorders (19%). Among the endoscopic findings concomitant with the diagnosis of PVDM, we highlight posterior laryngitis (71%), diseases of the nasal septum (18%), nasal polyps (7%). DiscussionFemale sex is more affected. There are several associations with other diseases, the main one being asthma, followed by rhinitis and psychiatric disorders. Obesity appears as a comorbidity in 24% of patients, as does sleep apnoea in 13%. Posterior laryngitis was the most common endoscopic finding. PVFM is an underdiagnosed disease, little known as it is a rare entity that still needs prospective studies. Exam standardization is important.

Long-term pulmonary sequelae in adolescents post-SARS-CoV-2 infection.

RationaleSevere acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) causes long‐term pulmonary sequelae in adults, but little is known about pulmonary outcomes in pediatrics.Objective(s)The aim of this study was to describe long‐term subjective and objective pulmonary abnormalities after SARS‐CoV‐2 infection in pediatric populations.MethodsSingle‐center, retrospective cohort of patients seen in post‐coronavirus disease 2019 (COVID‐19) pulmonary clinic in 2021. Subjects evaluated had persistent pulmonary symptoms 4 weeks or more after initial infection. Clinical testing included a 6‐min walk test (6MWT), chest X‐ray, pre‐ and postbronchodilator spirometry, plethysmography, and diffusion capacity. Patients were followed 2‐to‐3‐months after the initial visit with repeat testing. The primary outcome was the presence of abnormal pulmonary function testing. Secondary measures included variables associated with pulmonary outcomes.ResultsEighty‐two adolescents were seen at a median of 3.5 months postinfection, with approximately 80% reporting two or more symptoms at clinic presentation (cough, chest pain, dyspnea at rest, and exertional dyspnea). At follow‐up (~6.5 months) exertional dyspnea persisted for most (67%). Spirometry was normal in 77% of patients, but 31% had a positive bronchodilator response. No abnormalities were noted on plethysmography or diffusion capacity. Clinical phenotypes identified included inhaled corticosteroid responsiveness, paradoxical vocal fold motion disorder, deconditioning, and dysautonomia. Multivariable modeling demonstrated that obesity, anxiety, and resting dyspnea were associated with reduced 6MWT, while female sex and resting dyspnea were associated with higher Borg Dyspnea and Fatigues scores.ConclusionsThis is the largest study to date of pediatric patients with long‐term pulmonary sequelae post‐COVID‐19. Identified clinical phenotypes and risk factors warrant further study and treatment.

Factors impacting therapy duration in children and adolescents with Paradoxical Vocal Fold Movement (PVFM)

PurposeParadoxical Vocal Fold Movement (PVFM) may cause airway restriction and resulting dyspnea in the pediatric population. Therapy with a speech-language pathologist (SLP) is the primary treatment for children and adolescents diagnosed with Paradoxical Vocal Fold Movement (PVFM). This study examined treatment duration and factors predicting number of therapy sessions required. MethodsData were drawn from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. One hundred and twelve children and adolescents were included in this study. Participants were diagnosed with PVFM, followed for therapy with a SLP, and were subsequently discharged from therapy with successful outcomes. Extracted data included number of therapy sessions, PVFM symptoms, patient demographics, medical history, and comorbid diagnoses. Regression was used to determine factors predicting therapy duration. ResultsPatients completed an average of 3.4 therapy sessions before discharge. Comorbid behavioral health diagnosis (β = 1.96, t = 3.83, p < .01) and a history of upper airway surgeries (β = 1.26, t = 2.615, p = .01) were significant predictors of the number of therapy sessions required before discharge; both factors significantly increased therapy duration. Age, symptom trigger-type, reflux symptoms, and dysphonia did not predict therapy duration. Overall, our regression model accounted for 42% of the variance in number of sessions required (r2 = 0.42). ConclusionsOn average, 3.4 sessions of therapy with an SLP resolved PVFM symptoms. Children with a behavioral health diagnosis required an average of 5.45 sessions and those with a history of upper airway surgery an average of 4.3 sessions. Future work should examine the relationship between behavioral health care and PVFM treatment, as well as how PVFM treatment efficiency can be maximized. Level of evidence3.

Endoscopic aspects and associated factors in paradoxical vocal fold movement

IntroductionParadoxical vocal fold movement (PVFM) is a respiratory disorder related to inadequate movement of vocal folds during inspiration or expiration. Its epidemiology and pathogenesis are unknown. The present study describes the standardization of the examination performed in our service and the main endoscopic changes found, evaluating the prevalence of PVFM in patients with suggestive symptoms and describing the association of PVFM with asthma and other diseases. Materials and methodsRetrospective observational study of a series of cases over a 13-year period – adult patients referred for outpatient bronchoscopy due to suspected PVFM. ResultsWe analyzed 1131 laryngoscopies performed on patients referred for suspicion of PVFM from May 2006 to June 2019. Of these, 368 cases were excluded from the study. A total of 255 patients (33%) had a confirmed diagnosis of PVFM, 224 women (88%). The most frequent comorbidities found were asthma (62%), rhinitis (45%), gastro-oesophageal reflux disease (45%), obesity (24%), and psychiatric disorders (19%). Among the endoscopic findings concomitant with the diagnosis of PVDM, we highlight posterior laryngitis (71%), diseases of the nasal septum (18%), nasal polyps (7%). DiscussionFemale sex is more affected. There are several associations with other diseases, the main one being asthma, followed by rhinitis and psychiatric disorders. Obesity appears as a comorbidity in 24% of patients, as does sleep apnoea in 13%. Posterior laryngitis was the most common endoscopic finding. PVFM is an underdiagnosed disease, little known as it is a rare entity that still needs prospective studies. Exam standardization is important.

A Case of Paradoxical Vocal Fold Movement Due to Psychological Causes

Paradoxical vocal fold movement (PVFM) is a dystonic laryngeal disorder characterized by involuntary vocal fold adduction during inspiration and/or expiration. PVFM is uncommon and may aggravate airway obstruction. And patients with PVFM have a specific etiology; therefore, treatment must be individualized and given immediately. We present a case of 63-year-old male presenting with intermittent dyspnea. After multidisciplinary workup, we presumed psychogenic PVFM and evaluated with speech-language pathologist and psychologist. In this report, we describe a rare case of psychogenic PVFM patient.

Diagnostic and Therapeutic Outcomes Following Systematic Assessment of Patients with Concurrent Suspected Vocal Cord Dysfunction and Asthma

Vocal cord dysfunction (VCD) is present in 25% to 50% of patients with asthma. When both diagnoses are suspected, accurate diagnosis and targeted management represent a clinical challenge. To evaluate diagnostic and therapeutic outcomes following systematic assessment for patients with concurrent suspected VCD and asthma. Patients underwent systematic evaluation by clinical assessment and validated questionnaires, followed bymultidisciplinary management. VCD was confirmed by visualization of paradoxical vocal fold motion at baseline or following provocation. Asthma was confirmed by demonstrating variable airflow obstruction. Asthma medications were deescalated in those with low clinical probability of asthma and no variable airflow obstruction. Response to 2 or more sessions of speech pathology was assessed by subjective report and standardized questionnaires. Among 212 consecutive patients, 62 (29%) patients had both VCD and asthma, 54 (26%) had VCD alone, 51 (24%) had asthma alone, and 45 (21%) had neither. Clinician assessment and the Laryngeal Hypersensitivity Questionnaire both predicted laryngoscopy-confirmed VCD. Deescalation or discontinuation of asthma therapy was possible in 37 of 59 (63%) patients without variable airflow obstruction, and was most successful (odds ratio, 5.5) in the presence of laryngoscopy-confirmed VCD (25 of 31, or 81%) Patients with VCD responded subjectively to 2 or more sessions of speech pathology, but laryngeal questionnaire scores did not improve. Expert clinician assessment and the Laryngeal Hypersensitivity Questionnaire predict the presence of laryngoscopy-confirmed VCD. Systematic assessment for both VCD and asthma facilitates deescalation or discontinuation of unnecessary asthma medications. Subjective symptom improvement following speech pathology was not paralleled by laryngeal questionnaire scores in this cohort.

Demographic Differences in Clinical Presentation of Pediatric Paradoxical Vocal Fold Motion (PVFM)

ObjectivesParadoxical vocal fold motion (PVFM) is involuntary closure of the vocal folds during inspiration, often presenting in children and young adults. Although common symptoms and triggers are known, differences in clinical presentation based on patient demographics are unknown. This study characterizes differences in clinical presentation of pediatric PVFM based on age, sex, and race/ethnicity. MethodsWe reviewed electronic medical records of patients 0-21 years old with PVFM based on ICD codes from 2009 to 2019 within a tertiary academic health system. Demographics, symptoms, triggers, concurrent diagnoses, and laryngoscopy findings were abstracted. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression. ResultsAmong 96 individuals the mean age was 10.6 years (standard deviation ±6.5) and 66 (69%) were female. In comparison to 13-21 year olds, those 0-2 years more often had PVFM observed on laryngoscopy (OR = 17.84, 95% CI: 3.14-101.51) and had less shortness of breath (OR = 0.01, 95% CI: 0.00-0.09). Those 3-12 years had more asthma (OR = 3.07, 95% CI: 1.07-8.81) and cough (OR = 6.12, 95% CI: 1.77-21.13). Both 0-2 (OR = 0.07, 95% CI: 0.02-0.24) and 3-12 year olds (OR = 0.13, 95% CI: 0.04-0.40) presented less with activity as a trigger. Racial/ethnic minorities were more likely to present with pharyngeal findings (eg mucosal inflammation, adenotonsillar hypertrophy) on laryngoscopy (OR = 4.58, 95% CI: 1.45-15.37) compared to non-Hispanic Whites. Differences in clinical presentation by sex were not observed. ConclusionWe identified several differences in symptoms, triggers, and laryngoscopy findings in pediatric PVFM based on age and race/ethnicity. Associations between sex and clinical presentation were not observed.

Economic Burden Associated With Management of Paradoxical Vocal Fold Motion Disorder.

Paradoxical vocal fold movement (PVFM) is often misdiagnosed as asthma and tends to have a prolonged time to diagnosis. Study aims were to estimate the time from dyspnea onset to PVFM diagnosis, to estimate associated pre- and postdiagnosis direct and indirect healthcare cost, and to compare the cost of postdiagnosis care among patients who did and did not undergo standard-of-care speech therapy. Patients diagnosed with PVFM were identified retrospectively. Time from dyspnea symptom onset to diagnosis was measured. Direct costs consisting of office visits, procedures, and prescribed pharmaceuticals before and after diagnosis were calculated. Indirect costs associated with lost wages related to healthcare were also estimated. Costs for patients who initiated versus did not initiate speech therapy and who had successful versus unsuccessful therapy were compared. Among 110 patients, median time from dyspnea onset to PVFM diagnosis was 33 months (interquartile range [IQR] 5-60). Direct and indirect prediagnosis median costs were $8,625 (IQR $1,687-$35,812) and $736 (IQR $421-$1,579) while first year following dyspnea symptom onset median direct and indirect costs were $1,706 (IQR $427-$7,118) and $315 (IQR $131-$631). Median direct and indirect costs of care in the postdiagnosis year were $2,062 (IQR $760-$11,496) and $841 (IQR $631-$1,261). Pharmaceuticals were predominant cost drivers in all time periods. Of those who completed speech therapy, 85% had breathing symptom improvement while incurring significant cost savings compared to those whose symptoms persisted. Costs of care leading to diagnosis of PVFM are substantial. More efficient methods of identifying patients with PVFM are essential to reduce prolonged time to diagnosis and associated costs. NA Laryngoscope, 132:142-147, 2022.

Can the Expiratory Disproportion Index Distinguish PVFMD from Subglottic Stenosis in Obese Patients?

Expiratory disproportion index (EDI) is the ratio of forced expiratory volume in 1 second (FEV1) divided by peak expiratory flow rate (PEFR) multiplied by 100. Prominent EDI (>50) values can differentiate subglottic stenosis (SGS) from paradoxical vocal fold movement disorder (PVFMD), but this has not been verified when considering body habitus. We hypothesize that the predictive value of elevated EDI in differentiating SGS from PVFMD will be lower in obese patients than non-obese patients. Patients ≥ 18 years old with recorded PFT values, BMI, and airway imaging were reviewed retrospectively from 01/2011 to 10/2018. EDI was recorded for 4 cohorts: non-obese/SGS, non-obese/ PVFMD, obese/SGS, and obese/ PVFMD, to determine the mean EDI and the sensitivity/specificity of an elevated EDI. Mean EDI values were 69.32 and 48.38 in the non-obese SGS and PVFMD groups, respectively (P < .01). They were 58.89 and 47.67 in the obese SGS and PVFMD groups, respectively (P < .05). At a threshold of >50, EDI had a sensitivity of 90.0% and specificity of 51.6% in differentiating between SGS and PVFMD cases in non-obese patients and 51.6% and 63.6% in obese patients. Prior literature has established that EDI can distinguish SGS from PVFMD in the general population. Our results show that the mean EDI values were significantly different in both cohorts, but an elevated EDI was not as sensitive at identifying SGS cases in obese patients. This suggests that the EDI should be used with caution in obese patients and should not be relied upon to rule out SGS. 3.

Paradoxical Vocal Fold Motion in ALS Patient: A Case Report

Paradoxical vocal fold motion (PVFM) can occur at any stage of amyotrophic lateral sclerosis (ALS). PVFM results in glottic narrowing or complete blockage of airway in ALS patients, which eventually leads to respiratory insufficiency and sudden death. ALS typically presents initially with weakness of hands and bulbar musculature. Rarely, hoarseness is the initial symptom in ALS. This is a case report of how PVFM presents initially with hoarseness as a first symptom of ALS.

Reduced Asthma Medication Use after Treatment of Pediatric Paradoxical Vocal Fold Motion Disorder.

The primary objective of this study was to determine whether the diagnosis and treatment of pediatric Paradoxical Vocal Fold Motion Disorder (PVFMD) leads to decreased asthma medication use. Our secondary objective was to determine dyspnea outcomes following diagnosis and treatment for PVFMD. Prospective observational study. Patients with newly diagnosed PVFMD between the ages of 11 and 17 were recruited at a single pediatric institution. A medication questionnaire and Dyspnea Index (DI) were completed at the initial visit, at the first return visit, and at greater than 6 months post-diagnosis and therapy. Laryngeal Control Therapy (LCT) consisted of teaching breathing techniques and identifying emotional, physical, and environmental contributing factors and strategies to reduce them. Twenty-six patients were recruited to the study. There were 19/26 (73%) patients diagnosed with asthma prior to a diagnosis of PVFMD, and 26/26 (100%) patients were using an inhaler prior to the enrollment visit. Twenty-two (85%) patients completed follow-up questionnaires. Five patients participated in no therapy, seven patients in partial therapy, and 14 patients in full therapy. Significant reduction in asthma medication use was seen in the full therapy group (P< .05) and in those with exercise as their only trigger (P< .05). Furthermore, symptoms as scored by the DI decreased overall from 25.5 to 18.8 (P< .001). Diagnosis and treatment of pediatric PVFMD leads to a decline in asthma medication use in those patients who participate in at least two LCT sessions and in those with exercise-induced PVFMD. LCT for pediatric PVFMD leads to a significant decrease in symptoms as measured by the DI. 4 Laryngoscope, 131:1639-1646, 2021.

Muscle Tension Dysphagia Evaluation and Treatment

Purpose This clinical focus article introduces primary and secondary muscle tension dysphagia (MTDg) as a functional idiopathic dysphagia that is often encountered in the otolaryngology clinic setting. Critical aspects of clinical assessment and treatment approaches will be discussed. The presented case study will describe a multidisciplinary evaluation and efficacy of therapy. Conclusions MTDg is a diagnosis of exclusion for a functional idiopathic swallowing disorder associated with abnormal laryngeal muscle tension. Abnormal laryngeal muscle tension is often associated with disorders of laryngeal hyperresponsiveness such as muscle tension dysphonia, chronic cough, globus pharyngeus, and paradoxical vocal fold motion. MTDg patients may exhibit concurrent disorders of laryngeal hyperresponsiveness. Proper dysphagia and gastroesophageal screening are critical in diagnosis of MTDg and must not be omitted. Our studies have shown high treatment efficacy with unloading of laryngeal muscle tension with the use of voice therapy technique utilized in treatment of muscle tension dysphonia.

CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Tracheobronchomalacia and excessive dynamic airway collapse are conditions affecting the trachea and mainstem bronchi leading to respiratory symptoms through excessive central airway collapse (ECAC) during expiration. Patients with this condition often present with laryngeal pathology resulting in hoarseness, shortness of breath, dysphagia, or cough. Despite previous descriptions of the incidence of paradoxical vocal fold motion in this population, the various possible laryngeal abnormalities have not been characterized. METHODS: We performed a retrospective review of our prospectively collected institutional tracheobronchomalacia database. The most recent patients seen at the chest disease center during the previous and current year (2019-2020) were evaluated. Demographics, comorbidities, previous airway surgeries, and laryngoscopy results were included. Continuous outcomes are presented as means or medians based on the assessment of normality (Shapiro-Wilk test). Dichotomic outcomes are presented as proportions. RESULTS: A total of seventy patients were included in the study. The median age was 57 (49 – 64) and 55 patients were female (78.6%). The most common comorbidities were asthma in 46 (66.7%), gastroesophageal reflux in 41 (59.4%), and obstructive sleep apnea in 32 (46.4%) patients. Only 4 (5.8%) patients had a previous tracheostomy, while 7 (10.1%) had had a previous airway surgery. Out of 70 patients, 64 (91.4%) were evaluated by the laryngology service. Of the patients that were evaluated, 53 (82.8%) had at least one abnormality in their larynx. The most common findings were laryngeal hyperfunction/muscle tension dysphonia in 34 (53.1%), signs of laryngopharyngeal reflux in 27 (42.2%), and vocal fold hypomobility/paresis in 25 (39.1%) patients. More severe conditions like paradoxical vocal fold motion, laryngospasm, and vocal fold paralysis were present in 13 (20.3%), 2 (3.1%), and 2 (3.1%) patients respectively. CONCLUSIONS: ECAC patients have a high incidence of laryngeal disorders that may contribute to their respiratory symptomatology and deteriorate their health-related quality of life. For this reason, it is important to have a baseline laryngeal evaluation before any airway intervention, especially when respiratory symptoms are out of proportion to the degree of dynamic central airway collapse. CLINICAL IMPLICATIONS: Laryngeal pathology may be an additional cause of symptoms in patients with ECAC that can be overlooked if a detailed laryngoscopy evaluation is not conducted. Early identification and opportune intervention could lead to improved patient-centered outcomes. DISCLOSURES: No relevant relationships by Alex Chee, source=Web Response 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: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Pavan Mallur, source=Web Response No relevant relationships by Daniel Ospina-Delgado, source=Web Response No relevant relationships by Mihir Parikh, source=Web Response No relevant relationships by Jennifer Wilson, source=Web Response