Vocal Cord Dysfunction Patients Research Articles

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.

Use of Impulse Oscillometry to Detect Vocal Cord Dysfunction

Vocal cord dysfunction (VCD) is the inappropriate adduction of the vocal cords during the inspiratory phase. Diagnosing VCD can be difficult because expected flow volume loop abnormalities are not noted frequently. To diagnose through laryngoscopy, the symptoms must occur during testing. We hypothesized a difference in R5 low frequency resistance of Impulse Oscillometry (IOS) in VCD compared with asthma patients. GAAAI collected 71 records of children and adults with asthma (confirmed or suspected) and/or vocal cord dysfunction (confirmed or suspected) who underwent spirometric and oscillometric testing. A multivariate logistic regression was utilized to analyze whether oscillometric testing result z-scores (R5 z-score, R5-20 z-score, AX z-score) were significantly different based on whether the patient had asthma, VCD, or both. The spirometric results (FEV1 %pred, FVC %pred, FEV1/FVC) were also analyzed for differences. No findings among oscillometric or spirometric measurements were found to be significantly different among patients with asthma (n=51), VCD (n=2), and both (n=18). For VCD patients relative to asthma patients, the associate p-value is 0.574 for the predictor R5 z-score. For asthma/VCD patients relative to asthma patients, the associate p-value is 0.960 for the predictor R5 z-score. The results of this study questions the value of IOS as an investigative tool for diagnosing patients with VCD through R5 z-scores. Patients in all groups will continue to be added. Further analysis will include an asymptomatic/symptomatic variable.

Recurrent Laryngeal Nerve Injury and Swallowing Dysfunction in Neonatal Aortic Arch Repair

We evaluated the incidence, clinical effect, and recovery rate of vocal cord dysfunction (VCD) and swallowing dysfunction in neonates undergoing aortic arch repair. We retrospectively evaluated 101 neonates who underwent aortic arch reconstruction from 2008 to 2015. Direct flexible laryngoscopy was performed in 89 patients before initiation of postoperative oral feeding after Norwood (n= 63) and non-Norwood (n= 26) arch reconstruction. We defined VCD as immobility of vocal cords or their lack of coaptation and poor mobility. The incidence of VCD after aortic arch repair was 48% (n= 43). There was no significant difference between the VCD and non-VCD groups in postoperative length of stay, extubation failure, cardiopulmonary bypass, cross-clamp, selective cerebral perfusion time, operative death, and The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Congenital Heart Surgery Mortality Categories. Placement of gastrostomy (p= 0.03) and documented aspiration (p= 0.01) were significantly more common in VCD patients. The incidence of VCD was 41% (n= 26) after Norwood and 65% (n= 17) after non-Norwood repairs (p= 0.06). Gastrostomy was required in 44 Norwood patients vs 9 non-Norwood patients (p= 0.004). Median length of stay was similar in Norwood patients with or without VCD (p= .28) but was significantly longer in non-Norwood patients with VCD vs those without (p= 0.002). At follow-up direct flexible laryngoscopy, VCD recovery was 74% (14 of 19) in the Norwood group and 86% (12 of 14) in the non-Norwood group. The incidence of VCD and swallowing dysfunction in neonates undergoing aortic arch reconstruction is high. Patients with VCD have a significantly higher incidence of gastrostomy placement and aspiration. In the Norwood population, length of stay is not associated with presence or absence of VCD. More than 70% of patients in each group who had direct flexible laryngoscopy follow-up recovered vocal cord function.

Pursed Lips Inspiration for Vocal Cord Dysfunction

Paradoxical vocal cord motion (PVCM) during vocal cord dysfunction (VCD) generally occurs spasmodically and transiently. After we had experienced 36 cases of VCD and successfully treated with conservative treatment including "pursed lips inspiration" method, we experienced a boy who had persistent PVCM. It was observed his PVCM vanished when he breathed in through pursed lips, while it appeared again when he stopped pursed lips inspiration. An airway reflex has been reported where the negative pressure in the subglottic space resulting from the inspiratory effort against a narrowed glottis activates the vocal cord adductor. VCD is considered to have both acceleration of laryngeal closure reflex against airway stimuli and active adductive movement of vocal cords against negative pressure in the subglottic space as underlying factors. The pursed lips inspiration method enables VCD patients not only to accomplish slow and light breathing but also to decrease the difference in the pressure between the supra--and subglottic space by occluding the nasal cavity and voluntary puckering up of the mouth which generate negative pressure in the supraglottic space. This is the first report of the pursed lips inspiration method as a treatment for VCD. Pursed lips inspiration is a simple method which is easy to perform anytime, anywhere without any special equipment, and is considered to be worth trying for VCD.

Lebensqualität bei Jugendlichen mit Vocal Cord Dysfunction

Vocal cord dysfunction (VCD) is a functional breathing disorder. A psychosomatic aetiology has been discussed and associations with depression, anxiety disorders, and social stress have been reported. We have undertaken a screening of behavioural and emotional problems in adolescent patients using standardised questionnaires. Thirty-one patients (8 - 16 years) with the clinical suspicion of VCD were investigated using the Youth-Self-Report (YSR/11 - 18) and for the assessment of the parents we used the analoguous Child-Behaviour-Checklist (CBCL/6 - 18). YSR and CBCL contain two sub-areas: (a) competence scales that measure the child's participation in activities, social skills and school achievements and (b) items that contain subscales for emotional problems such as depressive and anxiety symptoms, conduct problems such as oppositional defiant problems and aggressive behaviour, social problems and physical complaints. On average, the features of VCD patients were not significantly different from those of the reference population. But we did observe tendencies of psychological problems (YSR 16.7 %, CBCL 20 %) compared with the standard (2 %) in the syndrome scales of both questionnaires Adolescents reported particularly more internalising disorders such as social retreat, physical complaint and anxiety and depressive symptoms. The parents reported more often "physical complaints" (13.3 %) and "aggressive behaviour" (10 %). We found tendencies of psychological strain, mainly social retreat, physical complaints and anxiety and depressive symptoms. Further investigations should focus on those emotional problems as well as on psychosomatically caused physical problems. Personality and psychological stress of the parents should be included in the investigation in order to evaluate the reports of the parents on higher aggressive behaviour and enhanced physical problems of their children in relation to their own psychological strain. We suggest family therapies, family counselling, or parental coaching as a therapeutic approach.

Vocal cord dysfunction in adolescents

Vocal cord dysfunction (VCD) often presents with dramatic and abrupt symptoms. To diagnose VCD, visualization by direct laryngoscopy is required and because patients are usually asymptomatic, a specific method to provoke VCD is needed. Approaches to predict VCD by alterations of the flow-volume loop have been investigated. Adolescents with clinical suspicion of VCD were invited to participate. After an initial pulmonary function test (PFT), direct laryngoscopy was performed. This was followed by a methacholine challenge test (MCT); the methacholine dose causing a 20% drop in forced expiratory volume after 1 sec (FEV(1) ) (PD(20) FEV(1) ) was calculated. Then a second laryngoscopy was conducted. PFT changes before and after MCT were compared with the data of 14 healthy controls (HCs). Thirty-five patients (8-19 years) were investigated. Three showed anatomical alterations. Of the remaining 32 patients, 14 had VCD and 18 had bronchial hyperresponsiveness (non-VCD). In 29 patients with a positive MCT, PD(20) FEV(1) methacholine was significantly lower in VCD compared with non-VCD (VCD 0.24 ± 0.4 mg, non-VCD 0.73 ± 0.73 mg, P = 0.0006). A PD(20) FEV(1) < 0.24 mg methacholine predicted VCD with a sensitivity of 85% and a specificity of 75%. VCD patients showed significantly lower PFT parameters after challenge; FEV(1) : VCD 58.5 ± 20.1%, non-VCD 80.2 ± 18.0%, and HCs 98.7 ± 16.6% (P < 0.0001). The combination of MCT and laryngoscopy may be able to differentiate between VCD and non-VCD. VCD patients showed a positive reaction at lower methacholine doses and displayed greater airway obstruction after MCT. PFTs and MCT do not replace direct laryngoscopy in the diagnosis of VCD in adolescents.

Irritant vocal cord dysfunction and occupational bronchial asthma: differential diagnosis in a health care worker

Vocal cord dysfunction (VCD) is an uncommon respiratory disease characterized by the paradoxical adduction of vocal cords during inspiration, that may mimic bronchial asthma. The pathogenesis of VCD has not been clearly defined but it is possible to recognize non-psychologic and psychologic causes. The majority of patients are female but, interestingly, a high incidence of VCD has been documented in health care workers. A misdiagnosis with asthma leads to hospitalisation, unnecessary use of systemic steroids with related adverse effects, and sometimes tracheostomy and intubation. In a subset of VCD patients, the disease can be attributed to occupational or environmental exposure to inhaled irritants. We report the case of a 45-year-old woman, working as a nurse, who complained of wheezing, cough, dyspnoea related to inhalation of irritating agents (isopropylic alcohol, formaldehyde, peracetic acid). She underwent chest radiography, pulmonary function assessment both in the presence and in the absence of symptoms, bronchial provocation with methacholine and bronchodilation test with salbutamol to recognize asthma's features, allergy evaluation by skin prick tests and patch tests and video-laryngoscopy. VCD diagnosis was made on the basis of video-laryngoscopy, that visualized the paradoxical motion of the vocal cords during symptoms, in the absence of other pathologic processes. This case fulfils the proposed criteria for the diagnosis of irritant VCD (IVCD). This is the first report of VCD onset following exposure to several irritants: formaldehyde, glutaraldehyde, sopropylic alcohol, peracetic acid-hydrogen peroxide mixture. These substances are used as cleaning and antiseptic agents in healthcare settings and some ones can also be found in many indoor environments. A correct diagnosis is important both to give the appropriate treatment and for medical legal implications.

High Levels of Medical Utilization by Ambulatory Patients With Vocal Cord Dysfunction as Compared to Age- and Gender-Matched Asthmatics

To evaluate medical utilization by ambulatory patients with vocal cord dysfunction (VCD). Retrospective, case-control study. Pulmonary disease clinic at an army tertiary-care center. Twenty-five ambulatory patients with VCD (mean age, 41 years; range, 27 to 69 years) who were age- (+/- 3 years) and gender-matched to 25 control patients with moderate persistent asthma. Medical utilization for the year preceding the diagnosis of VCD or asthma was obtained from a computerized medical record. End points included total outpatient visits, evaluations by subspecialty physicians, presentations for urgent care, hospitalizations, and number of prescriptions. Total physician visits (477 visits vs 267 visits, respectively; p < 0.004) and subspecialty care visits (277 visits vs 118 visits; p < 0.007) were significantly greater among the VCD cohort as compared with the asthmatic cohort. The groups were also found to have comparable utilization of prescriptions (448 prescriptions vs 394 prescriptions, respectively; p < 0.63), frequency of hospitalizations (seven hospitalizations vs five hospitalizations; p < 0.59), and urgent care visits (45 visits vs 20 visits; p < 0.14). Ambulatory VCD patients use significantly more medical provider resources and similar pharmaceutical assets as compared to patients with moderate persistent asthma.

Vocal Cord Dysfunction Patients Are High Users of Health Care

Vocal Cord Dysfunction Patients Are High Users of Health Care

Vocal Cord Dysfunction Patients Are High Users of Health Care

Vocal Cord Dysfunction Patients Are High Users of Health Care

High Levels of Medical Utilization By Ambulatory Patients with Vocal Cord Dysfunction as Compared to Age and Gender Matched Asthmatics

PURPOSE: Patients admitted to the hospital for vocal cord dysfunction (VCD) have been shown to have high medical utilization. In our practice patients with VCD are aggressively diagnosed, have milder disease, and are rarely hospitalized for VCD. Medical utilization by ambulatory VCD patients has never been studied but is perceived to be high.

Vocal Cord Dysfunction Induced by Methacholine Challenge Testing

To determine whether methacholine challenge testing (MCT) provokes vocal cord dysfunction (VCD), as evidenced by inspiratory vocal cord closure on direct laryngoscopy, and whether spirometry and flow-volume loops (FVLs) demonstrate any changes that are suggestive of VCD. Prospective, controlled study. Army medical center. Thirty-four subjects all with normal baseline spirometry. Ten subjects had documented evidence of VCD, 12 subjects had exercise-induced asthma (EIA) and reactive MCT, and 12 subjects served as healthy asymptomatic control subjects. Measurement of spirometry with FVLs and direct laryngoscopy of the vocal cords performed immediately before and after subjects had undergone MCT. Evidence of inspiratory vocal cord adduction was found in four VCD patients. Two patients had adducted vocal cords at baseline, and their conditions were unchanged after undergoing MCT. Two other patients had normal conditions at baseline and demonstrated acute inspiratory vocal cord adduction after undergoing MCT. None of the patients in the EIA or control groups had evidence of VCD at baseline or after undergoing MCT. Truncation of the inspiratory limb of the FVL after MCT was noted in five patients, which correlated with evidence of VCD in 60% of these patients. One EIA patient had truncation of the inspiratory FVL after MCT, and no changes were found in the control group. A comparison of spirometry between EIA patients and VCD patients with and without evidence of inspiratory vocal cord adduction during MCT showed no significant differences. The findings suggest that MCT may cause an acute episode of vocal cord adduction and that positive results may not reflect underlying reactive airways disease. However, a flattening or truncation of the inspiratory FVL after the patient undergoes MCT is not diagnostic for the presence of inspiratory vocal cord adduction.

Multidimensional voice program analysis (MDVP) and the diagnosis of pediatric vocal cord dysfunction

Vocal cord dysfunction (VCD) can present with signs and symptoms that mimic asthma. This may lead to unnecessary pharmacologic treatment or more invasive measures including intubation. Presently, the diagnosis of VCD can only be confirmed when a patient is symptomatic, via pulmonary function testing (PFT) or visualization of adduction of the vocal cords during inspiration by direct laryngoscopy. Multidimensional Voice Program (MDVP) analysis. a computer program which analyzes various aspects of voice, can detect abnormal voice patterns of patients with upper airway pathology. We determined whether MDVP analysis was useful in the diagnosis of VCD. We conducted chart reviews of patients referred to our department from 1995 to 1998 with the presumed diagnosis of VCD who had undergone MDVP analysis. The diagnosis of VCD was based on the presenting history, PFT results, laryngoscopy results, as well as voice evaluation conducted by a speech-language pathologist. We analyzed six consecutive patients referred for this investigation. We delineated common trends in the variables measured on MDVP analysis in VCD patients. and compared these with controls and other vocal cord pathology. Five cases of possible VCD had abnormalities in the MDVP variable of soft phonation index (SPI). All five also had abnormalities in the variation in fundamental frequency (vFo). In one case, MDVP analysis was conducted pre- and posttreatment for VCD, and SPI and vFo both normalized. In a sixth case of possible VCD. the diagnosis was not confirmed as the patient had normal PFTs and laryngoscopy. MDVP analysis was normal in this individual. The pattern of abnormal SPI and vFo was not seen in a group of normal controls or in patients with vocal cord nodules. MDVP analysis may be a useful tool when diagnosingVCD, as well as in evaluating response to treatment.

A Case of Vocal Cord Dysfunction Masqueraded as Exercised-Induced Asthma

Vocal cord dysfunction (VCD) is respiratory disorder characterized by paradoxical closure of the vocal cord during the respiratory cycle leading to obstructive airway symptoms. The clinical presentation of VCD is often dramatic and its misdiagnosis as asthma or exercise-induced brochospasm(EIB) has led to inappropriate treatment including high dose corticosteroids, intubation, and tracheostomy. Many VCD patients are asymptomatic at rest and require exercise challenge to elicit symptoms and vocal cord abnormalities. The gold standard for the diagnosis of VCD remains laryngoscopy or bronchoscopy with direct visualization of paradoxical adduction of the vocal cords. We report a case of exercise-induced Vocal cord masqueraded as exercise-induced asthma unresponsive to corticosteroids. And bronchodilator confirmed by typical bronchoscopic findings with paradoxial adduction of the vocal cords.

Vocal cord dysfunction after left lung resection for cancer.

To evaluate the prevalence, the impact-related postoperative complications and the risk factors of vocal cord dysfunction (VCD) after left lung resection for cancer. From February 1996 to April 1999, a review of prospectively gathered data was performed on 99 consecutive patients who underwent a pneumonectomy (n=50) or a lobectomy (n=49) with a mediastinal lymph node dissection. A fiber optic laryngeal examination was performed preoperatively for all patients and within the first week postoperatively in patients with symptom(s) or sign(s) of VCD or respiratory complications. Thirty-one patients (31%) had a postoperative VCD (group VCD) and 68 (68%) did not (group non-VCD). Mortality rate was 19% in group VCD and 9% in group non-VCD (P=0.13). Group VCD patients developed more pulmonary complications (P=0.014) and cardiac complications (P<0.001) compared to group non-VCD patients. A higher rate of reintubation (P=0.005), pneumonia (P=0.06), arrhythmia (P=0.002), cardiac failure (P<0.001) was noticeable in group VCD and may account for the higher rate of complications in this group. Using multivariate analysis, preoperative radiotherapy (P=0.001) and pneumonectomy (P=0.008) were predictive of postoperative VCD. Hospital stay was 22+/-16 days in group VCD and 13+/-9 days in group non-VCD (P<0.002). VCD is a frequent event that can lead to dramatic pulmonary complications. We would recommend to track it and to treat it as early as possible.