Effects of Exercise-Induced Laryngeal Obstruction in Adolescents: A Qualitative Study

PURPOSE

The purpose of this study was to examine the influence of exercise-induced laryngeal obstruction (EILO) on adolescents.

METHOD

Twenty patients (< 17 years) diagnosed with EILO participated in this study. Patients completed semistructured interviews examining their experience with the health care system, treatment, and the effects of EILO symptoms on quality of life. Interviews were analyzed using a combination of directed and conventional content analyses. Researchers identified seven overarching themes either prior to or during analysis, and 24 subthemes were inductively identified from patient interviews using open, axial, and selective coding.

RESULTS

On average, patients went 1.9 years between symptom onset and EILO diagnosis. Patients described symptom onset as frightening and confusing. Even after initially reporting symptoms to a medical provider, patients went an average of 10.5 months before diagnosis. Patients perceived that delays in diagnosis prevented efficient management and allowed symptoms to escalate. Patients reported that EILO detrimentally influenced athletic performance, forcing them to pace themselves or cease participation altogether. Social and academic effects of EILO included missed classes, difficulty in physical education courses, and resentment from teammates if athletic performance declined. Both athletes and nonathletes indicated that EILO elicited feelings of fear, frustration, dread, guilt, and embarrassment. Patients reported that therapy with a speech-language pathologist (SLP) effectively addressed symptoms; however, employing rescue breathing techniques was often more difficult than anticipated.

CONCLUSIONS

Physical and emotional sequelae associated with EILO may have widespread influence on patient quality of life. Therapy with an SLP reportedly ameliorated EILO symptoms; however, patients indicated that delayed diagnosis allowed negative effects to intensify prior to treatment.

A speech therapy treatment protocol for exercise induced laryngeal obstruction

Background

Exercise induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, relevant to 5%-7% of young people. It is caused by paradoxical inspiratory adduction of laryngeal structures and diagnosed by continuous visualization of the larynx during high intensity exercise. Empirical data suggest that EILO consists of different subtypes that require different therapeutic approaches. Currently applied treatment approaches do not rest on randomized controlled trials (RCTs), and thus evidence-based guidelines cannot be established. This protocol describes the speech therapy treatment approach which is applied to EILO patients in a large prospective RCT called HelpILO.

Methods and analysis

Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital are randomized into four treatment arms. Speech therapy is represented in two of these, provided in a structured manner based on general speech therapy principles and abdominal breathing, combined with experience obtained with these patients at our hospital during the last decades. The main outcome measure of HelpILO is changes of laryngoscopically visualized laryngeal adduction, rated at peak exercise before vs. after interventions, using a validated scoring system.

Ethics and dissemination

Despite widespread use of speech therapy in patients with EILO, this approach is insufficiently tested in RCTs, and the study is therefore considered ethically appropriate. The study will provide knowledge listed as a priority in a recent statement issued by major respiratory and laryngological societies and requested by clinicians and researchers engaged in this area. The results will be presented at relevant conferences, patient fora, and media platforms, and published in relevant peer reviewed international journals.

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

OBJECTIVES

Paradoxical 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.

METHODS

We 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.

RESULTS

Among 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.

CONCLUSION

We 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.

Prevalence and characterisation of exercise-induced laryngeal obstruction in patients with exercise-induced dyspnoea

OBJECTIVE

The prevalence of exercise-induced laryngeal obstruction is largely unknown. This study aimed to evaluate the prevalence of this condition in a selected study population of patients with exercise-induced dyspnoea.

METHOD

A retrospective analysis was conducted of demographic data, co-morbidities, medication, symptoms, performance level of sporting activities, continuous laryngoscopy exercise test results and subsequent treatment.

RESULTS

Data from 184 patients were analysed. The overall prevalence of exercise-induced laryngeal obstruction in the study population was 40 per cent, and the highest prevalence was among females aged under 18 years (61 per cent). However, a high prevalence among males aged under 18 years (50 per cent) and among adults regardless of gender (34 per cent) was also found.

CONCLUSION

The prevalence of exercise-induced laryngeal obstruction is clinically relevant regardless of age and gender. Clinicians are encouraged to consider exercise-induced laryngeal obstruction as a possible diagnosis in patients suffering from exercise-induced respiratory symptoms. No single characteristic that can distinguish exercise-induced laryngeal obstruction from other similar conditions was identified.

A multidimensional strategy to managing dysfunctional breathing and exercise-induced laryngeal obstruction in adolescent athletes

BACKGROUND

Exercise induced laryngeal obstruction (EILO) causes inspiratory distress in the upper airway in many adolescent athletes. The nature of EILO is not fully understood, and effective management strategies are lacking. This study aimed to assess the effectiveness of a multidimensional individually tailored intervention, including Norwegian Psychomotor Physiotherapy (NPMP), elements of cognitive behavioural therapy and a rehabilitation plan, in reducing inspiratory distress and dysfunctional breathing in adolescent athletes with EILO.

METHODS

A mixed methods design, which combined qualitative and quantitative research, was used. Data, including subjective experiences of respiratory distress, findings from body examinations and objective measurements of lung function and aerobic capacity were gathered before and after a five month intervention involving 18 participants.

RESULTS

Following the intervention, the participants showed a reduction in respiratory distress and anxiousness associated with their breathing difficulties. Furthermore, the participants reported to be more in control of their breathing. The body assessments revealed a more functional breathing motion and improved posture, which imply that the breathing was less thoracic and more diaphragmatic in rest and exercise in all participants after the intervention.

CONCLUSIONS

Our results suggest that a multidimensional individually tailored intervention, including NPMP based physiotherapy, cognitive behavioural therapy elements, and a rehabilitation plan may reduce inspiratory distress and dysfunctional breathing in athletes with EILO.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol Registration and Results system NCT06033755, date of registration: September12, 2023. Retrospectively registered.

Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction

PURPOSE

This study examined treatment outcomes of speech-language pathology intervention addressing exercise-induced laryngeal obstruction (EILO) symptoms in teenage athletes.

METHOD

A prospective cohort design was utilized; teenagers diagnosed with EILO completed questionnaires during initial EILO evaluations, posttherapy, 3-month posttherapy, and 6-month posttherapy. Questionnaires examined the frequency of breathing problems, the use of the techniques taught in therapy, and the use of inhaler. Patients completed the Pediatric Quality of Life (PedsQL) inventory at all time points.

RESULTS

Fifty-nine patients completed baseline questionnaires. Of these, 38 were surveyed posttherapy, 32 at 3-month posttherapy, and 27 at 6-month posttherapy. Patients reported more frequent and complete activity participation immediately posttherapy (p = .017) as well as reduced inhaler use (p = .036). Patients also reported a significant reduction in the frequency of breathing problems 6-month posttherapy (p = .015). Baseline PedsQL physical and psychosocial scores were below normative range and were not impacted by therapy. Baseline physical PedsQL score significantly predicted frequency of breathing difficulty 6-month posttherapy (p = .04), as better baseline scores were associated with fewer residual symptoms.

CONCLUSIONS

Therapy with a speech-language pathologist for EILO allowed for more frequent physical activity following therapy completion and decreased dyspnea symptoms 6-month posttherapy. Therapy was associated with a decrease in inhaler use. PedsQL scores indicated mildly poor health-related quality of life even after EILO symptoms improved. Findings support therapy as an effective treatment for EILO in teenage athletes and suggest that dyspnea symptoms may continue to improve following discharge as patients continue using therapy techniques.

Multi-Institutional Study of Patient-Reported Outcomes of Paradoxical Vocal Fold Motion

OBJECTIVE

To explore patient-reported outcome measures of pediatric paradoxical vocal fold motion through a multi-institutional study of geographically diverse United States medical facilities to assess long-term management and outcomes.

METHODS

Eligible participants >8 years of age diagnosed with PVFM over a 10-year period from 7 tertiary pediatric hospitals were invited to complete a survey addressing study objectives.

RESULTS

65 participants completed the survey, of whom 80% were female, 75% reported a 3.5 grade point average or better, and 75% identified as competitive athletes or extremely athletic individuals. Participants rated their perceived efficacy of 13 specific treatments. Only five treatments were considered effective by a majority of the participants who tried them. The treatments that participants tried most often were breathing exercises (89.2%), bronchodilator treatments (45%), and allergy medications (35.4%). 78.8% of participants reported receiving more than one treatment and 25% reported receiving a combination of bronchodilators, anticholinergics, and steroids. At the time of PVFM diagnosis, 38% of participants had no idea when their symptoms would completely resolve. 23.3% of participants did not experience symptom resolution until greater than 1 year after diagnosis.

CONCLUSIONS

Traditional management tools such as breathing exercises and biofeedback treatments may not provide the long-term benefit that providers anticipate. In addition to these commonly used management strategies, highly efficacious techniques such as counseling and lifestyle management should be incorporated into the long-term management of patients whose symptoms are refractory to traditional care.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:970-976, 2023.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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 2 at 3 weeks (IQR 3) compared to group 1 at 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.

CONCLUSION

Using a fast-track screening questionnaire for pediatric PVFMD patients significantly decreases the time to treatment without altering the response rate of LCT.

The Reliability of the Arabic Version of the Dyspnea Index Questionnaire for Upper Airway-Related Dyspnea

Objectives

This study aimed to translate the Dyspnea Index (DI) questionnaire into the Arabic language and determine whether this version is valid and reliable for Arabic-speaking patients with upper airway-related dyspnea.

Methods

A cross-sectional study was conducted at the King Saud University Medical City otolaryngology clinics in Riyadh, Saudi Arabia. The DI questionnaire was translated into Arabic and then back-translated into the English language. Inclusion criteria were preoperative patients presenting to the otolaryngology clinic with upper airway-related dyspnea between November and December 2020. The results of internal consistency and factor analysis among the items were compared to the original DI development results to assess the reliability of the questionnaire.

Results

Among a total of 57 recruited patients, 50 questionnaires were completed with an 88% response rate. The mean age of the included patients was 38 ±14 years. Women constituted 58% of the patients. The most common diagnosis was subglottic stenosis (72%). Principle component extraction in factor analysis revealed a single underlying factor for all the questions. Factor loading ranged from 0.69 to 0.85. Reliability statistics showed a high value of internal consistency among the items. The mean inter-item correlation was 0.58.

Conclusion

Based on our findings, the Arabic version of the DI questionnaire is a reliable instrument for evaluating upper airway dyspnea.

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

PURPOSE

Paradoxical 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.

METHODS

Data 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.

RESULTS

Patients 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).

CONCLUSIONS

On 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.

International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 2: non-infective acute respiratory illness

Acute respiratory illness (ARill) is common and threatens the health of athletes. ARill in athletes forms a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to non-infective ARill in athletes. The International Olympic Committee (IOC) Medical and Scientific Committee appointed an international consensus group to review ARill in athletes. Key areas of ARill in athletes were originally identified and six subgroups of the IOC Consensus group established to review the following aspects: (1) epidemiology/risk factors for ARill, (2) infective ARill, (3) non-infective ARill, (4) acute asthma/exercise-induced bronchoconstriction and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport (RTS) and (6) acute nasal/laryngeal obstruction presenting as ARill. Following several reviews conducted by subgroups, the sections of the consensus documents were allocated to 'core' members for drafting and internal review. An advanced draft of the consensus document was discussed during a meeting of the main consensus core group, and final edits were completed prior to submission of the manuscript. This document (part 2) of this consensus focuses on respiratory conditions causing non-infective ARill in athletes. These include non-inflammatory obstructive nasal, laryngeal, tracheal or bronchial conditions or non-infective inflammatory conditions of the respiratory epithelium that affect the upper and/or lower airways, frequently as a continuum. The following aspects of more common as well as lesser-known non-infective ARill in athletes are reviewed: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations and risks of illness during exercise, effects of illness on exercise/sports performance and RTS guidelines.

Exercise-induced laryngeal obstruction (EILO) in athletes: a narrative review by a subgroup of the IOC Consensus on 'acute respiratory illness in the athlete'

Exercise-induced laryngeal obstruction (EILO) is caused by paradoxical inspiratory adduction of laryngeal structures during exercise. EILO is an important cause of upper airway dysfunction in young individuals and athletes, can impair exercise performance and mimic lower airway dysfunction, such as asthma and/or exercise-induced bronchoconstriction. Over the past two decades, there has been considerable progress in the recognition and assessment of EILO in sports medicine. EILO is a highly prevalent cause of unexplained dyspnoea and wheeze in athletes. The preferred diagnostic approach is continuous visualisation of the larynx (via laryngoscopy) during high-intensity exercise. Recent data suggest that EILO consists of different subtypes, possibly caused via different mechanisms. Several therapeutic interventions for EILO are now in widespread use, but to date, no randomised clinical trials have been performed to assess their efficacy or inform robust management strategies. The aim of this review is to provide a state-of-the-art overview of EILO and guidance for clinicians evaluating and treating suspected cases of EILO in athletes. Specifically, this review examines the pathophysiology of EILO, outlines a diagnostic approach and presents current therapeutic algorithms. The key unmet needs and future priorities for research in this area are also covered.

Stressed and Distressed: Potential Underpinnings of Exercise-Related Inspiratory Distress in Adolescent Sport Performers

Many adolescent sport performers present with exercise-related respiratory symptoms consistent with exercise-induced laryngeal obstruction (EILO). The pathogenic underpinnings of EILO are not fully resolved, and existing behavioral management includes therapies targeting laryngeal physiology whereas surgical interventions target laryngeal anatomical anomalies. Recent findings from research and clinical practice indicate that psychological stress and thoracic breathing co-occur with laryngeal tightness in adolescent sport performers with EILO. This Perspective article theorizes on this potential coexistence. It discusses possible underpinnings of respiratory symptoms (including EILO) and thoracic breathing in adolescent sport performers by considering the effects of various stressors to which adolescent sport performers are exposed, and the impact these may have on the breathing, including in terms of laryngeal narrowing. The effect of stress on the breathing is examined in light of the reciprocal communication between the brain and the body and the relationship between psychological stress and stress responses in the respiratory system mediated by the autonomic nervous system. To inform decision-making and clinical awareness in this area, it may be worth expanding the focus from targeting mainly laryngeal structures to also include constrictions of the airways and the effects of thoracic breathing on the larynx during exercise. The importance of considering respiratory distress from a multidimensional perspective, and of incorporating the complexity of sport performers' psychological and physical experiences in the management of their health and well-being, is emphasized.

IMPACT

This Perspective adds to the understanding of respiratory distress in populations other than adults, which is important and necessary.

LAY SUMMARY

Adolescent sport performers are exposed to a number of stressors that may affect breathing and laryngeal narrowing, which in turn may have implications for the management of their overall health and well-being.

Exercise-induced Laryngeal Obstruction: Protocol for a Randomized Controlled Treatment Trial

BACKGROUND

Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, caused by paradoxical inspiratory adduction of laryngeal structures, and diagnosed by continuous visualization of the larynx during high-intensity exercise. Empirical data suggest that EILO consists of different subtypes, possibly requiring different therapeutic approaches. Currently applied treatments do not rest on randomized controlled trials, and international guidelines based on good evidence can therefore not be established. This study aims to provide evidence-based information on treatment schemes commonly applied in patients with EILO.

METHODS AND ANALYSIS

Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital will be randomized into four non-invasive treatment arms, based on promising reports from non-randomized studies: (A) standardized information and breathing advice only (IBA), (B) IBA plus inspiratory muscle training, (C) IBA plus speech therapy, and (D) IBA plus inspiratory muscle training and speech therapy. Differential effects in predefined EILO subtypes will be addressed. Patients failing the non-invasive approach and otherwise qualifying for surgical treatment by current department policy will be considered for randomization into (E) standard or (F) minimally invasive laser supraglottoplasty or (G) no surgery. Power calculations are based on the main outcomes, laryngeal adduction during peak exercise, rated by a validated scoring system before and after the interventions.

ETHICS AND DISSEMINATION

The study will assess approaches to EILO treatments that despite widespread use, are insufficiently tested in structured, verifiable, randomized, controlled studies, and is therefore considered ethically sound. The study will provide knowledge listed as a priority in a recent statement issued by the European Respiratory Society, requested by clinicians and researchers engaged in this area, and relevant to 5-7% of young people. Dissemination will occur in peer-reviewed journals, at relevant media platforms and conferences, and by engaging with patient organizations and the healthcare bureaucracy.

Dyspnea Index: An upper airway obstruction instrument; translation and validation in Swedish

OBJECTIVE

Upper airway dyspnoea is a challenging condition in which assessing the discomfort experienced by the patient is essential. There are three patient-reported outcome (PRO) instruments developed particularly for this patient group, none of which is available in Swedish. The aim of this study was to translate the Dyspnea Index (DI) into Swedish and validate the instrument for use in the Swedish-speaking population by investigating its basic psychometric properties.

DESIGN

A prospective instrument validation study.

SETTING

Tertiary referral centre.

PARTICIPANTS

Fifty-three (n = 53) patients with upper airway dyspnoea and 19 healthy controls.

MAIN OUTCOME MEASURES

The questionnaire was translated into Swedish (swDI) with a forward-backward method. Reliability, repeatability, responsiveness and construct validity were assessed by asking the subjects to complete the swDI, a visual analog scale (VAS) at exertion and at rest and the Voice Handicap Index (VHI).

RESULTS

The swDI showed excellent internal consistency (Cronbach's α: 0.85) and repeatability (interclass correlation coefficient: 0.87 and Pearson's r: .89) in the patient group. No ceiling effect was observed (maximum score achieved was 39; 85% of the patients scored ≤ 36). SwDI scores moderately correlated with VAS at exertion (r: .59) and at rest (r: .42), yet poorly with the VHI (r: .36). The effect size (ES) was 3.8.

CONCLUSIONS

The swDI is a valid, robust and reliable questionnaire for self-assessment in Swedish-speaking patients with upper airway obstruction. A future anchor-based longitudinal study is needed to assess the smallest detectable change (SDC) and minimal important change (MIC) that were not estimated in our study.

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

OBJECTIVES/HYPOTHESES

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.

STUDY DESIGN

Prospective observational study.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1639-1646, 2021.

Struggling to Breathe: Inspiratory Muscle Training in Adolescent Athletes

OBJECTIVE

Dyspnea is a primary characteristic of exercise-induced laryngeal obstruction and prevents individuals from inhaling and exhaling without effort. This single subject research study investigated the effects of inspiratory muscle training (IMT) on exercise-induced symptoms characteristic of exercise-induced laryngeal obstruction in adolescent athletes.

METHODS

Five weeks of IMT was provided to five adolescent athletes, four females and one male, aged 10 to 16. Variables that were measured prior to, during, and after completion of IMT program included maximum phonation time, maximum perceived breathlessness, duration of running, and quality of life regarding dyspnea.

RESULTS

Results showed a reduction in maximum perceived breathlessness as well as a significant increase in maximum phonation time across participants. The majority of participants rated their quality of life regarding dyspnea as significant improved after IMT.

CONCLUSIONS

These findings contribute to the increasing body of literature investigating the use of alternative therapy strategies for treatment of symptoms of exercise-induced laryngeal obstruction in adolescent athletes.

Outcomes of Paradoxical Vocal Cord Motion Diagnosed in Childhood

OBJECTIVES

To explore long-term patient reported outcome (PRO) measures of pediatric paradoxical vocal cord motion (PVCM) including ease of diagnosis, management, symptom duration and effect on quality of life.

METHODS

All children >8 years of age diagnosed with PVCM at a tertiary pediatric hospital between 2006 and 2017 were invited to complete a survey addressing study objectives.

RESULTS

21/47 eligible participants could be contacted and 18/21 (86%) participated. 78% were female with a mean age at diagnosis of 11.6 and 15.0 years at survey completion. Common PVCM symptoms reported were dyspnea (89%), globus sensation (56%), and stridor (50%). The median time to diagnosis was 3 months (IQR 2-5 months). Nearly all reported being misdiagnosed with another condition, usually asthma, until being correctly diagnosed usually by an otolaryngologist. Participants reported undergoing 3.7 diagnostic studies (range 0-8); pulmonary function testing was most common. Of numerous treatments acknowledged, breathing exercises were common (89%) but only reported helpful by 56%. Use of biofeedback was recalled in 1/3 of subjects but reported helpful in only 14% of them. Anti-reflux, allergy, anticholinergics, inhalers and steroids were each used in >50%, but rarely reported effective. PVCM was reportedly a significant stressor when initially diagnosed but despite 2/3 of participants still reporting ongoing PVCM symptoms, the perceived stress significantly decreased over time (Z = 3.26, P = 0.001).

CONCLUSIONS

This first PVCM PRO study endorses that diagnosis is often delayed and prescribed treatments often viewed as ineffective. While biofeedback and breathing exercises may be critical for short-term control of PVCM episodes, lifestyle changes and stress reduction are likely necessary for long-term management. Increased awareness and improvements in management are needed for this condition.

A Trigger Reduction Approach to Treatment of Paradoxical Vocal Fold Motion Disorder in the Pediatric Population

OBJECTIVES

Paradoxical vocal fold motion disorder (PVFMD), or induced laryngeal obstruction (ILO), is a clinical phenomenon characterized by inappropriate adduction of the true vocal folds during inspiration. The resultant episodes of acute respiratory distress marked by exercise-induced cough, inspiratory stridor, throat tightness, and shortness of breath are often misattributed to asthma despite normal pulmonary function testing results. Although the pathogenesis of the disease remains unclear, the etiology is likely multifactorial with an inflammatory, neurological, and psychiatric basis. Our trigger reduction approach, consisting of a plant-based, Mediterranean-style diet to treat laryngopharyngeal reflux and sinus toilet, aims to dampen the peripheral neuronal hyperexcitability of the laryngopharyngeal tissues that is hypothesized to contribute to this disorder. The primary objective of the present study was to assess for therapeutic efficacy by analyzing pre- and post-treatment subjective scores using four validated indices: Voice Handicap Index (VHI), Reflux Symptom Index (RSI), Dyspnea Index (DI), and Cough Severity Index (CSI).

METHODS

A retrospective chart review of all patients age ≤18 years seen by the senior author between 2012 and 2018 who reported laryngeal spasm (J35.5) as a presenting complaint with no underlying organic diagnosis that otherwise explained the symptom identified the study cohort. Patients were excluded if another cause of their laryngeal spasm was identified or their medical records were incomplete.

RESULTS

Of 80 patients, 24 met the criteria. The most frequent presenting symptom was exercise-induced dyspnea (79%). Of the four measured indices, only a change in DI (P = 0.024) met statistical significance. Of 24 patients, 18 (75%) demonstrated a reduction in DI following our treatment protocol. Using reduction in DI as a continuous variable to assess response, the patient cohort experienced a 4.62 (95% confidence interval [CI]: 0.65-8.6) mean point reduction. Using the eight-point reduction (improvement) in DI as an accepted clinical response to treatment, 8 of 24 patients (33%) experienced a clinically relevant response. Changes in CSI (P = 0.059), RSI (P = 0.27), and VHI (P = 0.25) did not meet statistical significance. Of 24 patients, 8 (33%), 11 (46%), and 7 (29%) demonstrated a reduction in CSI, RSI, and VHI following our trigger reduction protocol, respectively. The patient cohort experienced a mean point reduction of 1.8 (95% CI: -0.1 to 3.7), 1.3 (95% CI: -1.1 to 3.7), and 1.3 (95% CI: -1.0 to 3.6) in CSI, RSI, and VHI, respectively.

CONCLUSIONS

Paradoxical vocal fold motion disorder is a multifactorial disease that poses diagnostic and therapeutic challenges. Early diagnosis and treatment are critical to ensure patient safety, satisfaction, and reduction in health care costs, as mistreatment with asthma pharmacotherapy, intubation, or tracheostomy may exacerbate their dyspnea and lead to preventable hospitalizations. Our results demonstrate that a trigger reduction approach consisting of a plant-based, Mediterranean-style diet and sinus toilet alone may not achieve a clinically meaningful response in the majority of patients. However, given their favorable safety profile, our therapeutic regimen, along with respiratory retraining therapy, may provide symptom relief for selected patients who would otherwise continue to suffer.

Short-Term Intensive Therapy and Outcomes for Athletes With Paradoxical Vocal Fold Motion Disorder

Purpose The aim of the study was to develop a treatment for athletes with paradoxical vocal fold motion disorder (PVFMD) based on exercise physiology and learning theory principles and administer it over a preestablished time frame. Method A prospective, repeated-measures, within-subject group design was used. Eleven adolescent/teen athletes diagnosed with PVFMD via laryngoscopy received short-term intensive (STI) therapy. Eight of the athletes returned for extended follow-up. Changes in postexercise inspiratory ( R _i) and expiratory ( R _e) resistances and Modified Borg Dyspnea Scale (MBDS) ratings collected at baseline were compared immediately posttreatment and at extended follow-up. Dyspnea Index scores were collected at baseline and at extended follow-up. Two no-treatment control athletes with PVFMD participated in two exercise challenges-baseline and 6 weeks later. Results Immediately after STI therapy, athletes attained significant improvement in R _i, R _e, and MBDS ratings. These changes were maintained at extended follow-up as well as a significant change in Dyspnea Index scores. The 2 control athletes who were reassessed 6 weeks after baseline experienced negative changes in postexercise R _i and MBDS ratings. Conclusion STI therapy that incorporated individuality, specificity, and variable practice effectively changed outcome measures posttreatment with further improvement observed at extended follow-up. These results provide preliminary evidence for STI therapy for PVFMD.

Exercise-Induced Laryngeal Obstruction: When Pediatric Exertional Dyspnea Does not Respond to Bronchodilators

Exertional dyspnea is a common complaint in general pediatric practice. While a high proportion of the general pediatric population has asthma, other diagnoses, including exercise-induced laryngeal obstruction should be considered, especially when asthma therapy is not sufficient to control symptoms. This review describes some of the key clinical features of exercised-induced laryngeal obstruction as well as preferred diagnostic and therapeutic approaches. Importantly, current diagnostic technology has considerably improved in the last decade at specialty centers. At the same time, infrastructure for clinical trials is emerging and there is not strong evidence to support specific therapies at the current time.

The Study of Laryngoscopic and Autonomic Patterns in Exercise-Induced Laryngeal Obstruction

OBJECTIVES

(1) Identify laryngeal patterns axiomatic to exercise-induced laryngeal obstruction (EILO) and (2) investigate the role of autonomic function in EILO.

METHODS

Twenty-seven athletic adolescents (13 EILO, 14 control) underwent laryngoscopy at rest and exercise. Glottal configurations, supraglottic dynamics, systolic blood pressure responses, and heart rate recovery were compared between conditions and groups.

RESULTS

Inspiratory glottal angles were smaller in the EILO group than the control group with exercise. However, group differences were not statistically significant ( P > .05), likely due to high variability of laryngeal responses in the EILO group. Expiratory glottal patterns showed statistically greater abductory responses to exercise in the control group ( P = .001) but not the EILO group ( P > .05). Arytenoid prolapse occurred variably in both groups. Systolic blood pressure responses to exercise were higher in the control group, and heart rate recovery was faster in the EILO group. However, no significant differences were seen between the 2 groups on either autonomic parameter ( P > .05).

CONCLUSIONS

"Paradoxical" inspiratory and blunted expiratory vocal fold pattern responses to exercise best characterize EILO. Group differences were only seen with exercise challenge, thus highlighting the utility of provocation and control groups to identify EILO.

Exercise-induced laryngeal obstruction in athletes: Contributory factors and treatment implications

Otherwise healthy adolescent athletes presenting with respiratory symptoms consistent with exercise-induced laryngeal obstruction (EILO) are frequently encountered in clinical practice. The symptoms are often incorrectly considered to result from exercise-induced asthma, and may be wrongly treated as such. Given the potential implications for health and performance if EILO is left untreated, a more comprehensive understanding of contributory mechanisms is essential in order to create appropriate treatment procedures. Informed by knowledge from physical therapy, as well as the fields of voice rehabilitation and vocal pedagogy, this theoretical article presents a novel way of understanding and managing EILO by exploring bodily mechanisms and structures that may disturb laryngeal function during strenuous exercise. Firstly, the status quo of the EILO diagnosis, its aetiology and treatment options are reviewed. Secondly, considerations associated with laryngeal structures and mechanisms, and their potential influence on laryngeal movement and sensitivity are examined. Thirdly, the manner in which postural de-alignment and breathing pattern may interfere with laryngeal functioning will be discussed. Finally, interventions for voice disorders and singing and the relevance of these for EILO are evaluated. It is argued that clients with EILO should undergo a thorough physical examination to identify constrictions in the body as a whole - such as postural de-alignments and a dysfunctional breathing pattern - as these are hypothesized as playing a critical role in laryngeal tightness during exercise. Physical therapists possess particular skills and competence with regard to examining breathing patterns and postural de-alignments, and should be included in the treatment process of EILO.

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

INTRODUCTION

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Exercise induced laryngeal obstruction: a review of diagnosis and management

Exercise induced laryngeal obstruction (EILO) is a condition where inappropriate vocal cord or glottic closure occurs during exercise. This review of the literature provides an overview of the current understanding of the definition, epidemiology, diagnosis and management of EILO. Using The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines the Cochrane, Embase, Ovid MEDLINE and PubMed databases were searched. Four search domains “exercise”, “induced”, “laryngeal” and “obstruction” were used. Primary searching found 469 records, 308 were excluded following screening of titles and citation. 100 were duplicates, a further 47 studies were excluded after applying inclusion and exclusion criteria. Two studies were identified following cross-referencing. A total of 15 studies were included. The last search date was 6/06/15. Average prevalence in the general adolescent population and athletes was 7.1 and 35.2 %, respectively. Dyspnoea was reported in 96.5, 99 and 100 % of three EILO patient cohorts. Two studies (n = 107) reported continuous laryngoscopy during exercise (CLE) testing could differentiate between patients and controls. In two studies (n = 33) the visual analogue scale (VAS) showed a beneficial effect of endoscopic supraglottoplasty (ES). Thirty-eight out of 43 patients who received two or more laryngeal control therapy sessions (LCT) had improvement or resolution of EILO symptoms. Exercise induced dyspnoea is the most common EILO symptom. EILO has a high occurrence in adolescents and athletes. The CLE test is the current gold standard for EILO diagnostics. Management of EILO includes both surgical and non-surgical interventions.

Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery

Exercise-induced laryngeal obstruction (E-ILO) causes exertional dyspnoea. There is no standardised methodology which characterises laryngeal obstruction in relation to exercise or links laryngeal obstruction and dyspnoea severity. Continuous laryngoscopy during exercise (CLE) may improve diagnostic sensitivity by enabling laryngeal visualisation at peak work capacity in patients with rapidly resolving obstruction. The time course of laryngeal obstruction across exercise and recovery has not been quantitated until this report.

Adolescents and young adults referred for CLE were laryngoscopically monitored across rest, maximal cycle ergometry exercise, and recovery. Three reviewers, blinded to time sequencing, rated inspiratory glottic and supraglottic obstruction during 10 windows of 15-s corresponding to rest, 25%, 50%, 75%, 90% and 100% of individual symptom-limited peak work capacity (expressed in Watts), and four consecutive recovery windows.

85 patients were screened and 71 included. Over 96% of time windows were interpretable. Laryngeal obstruction severity reached observed maximal levels at peak work capacity, and rapidly resolved. A spectrum of observed maximal obstruction was measured.

CLE provides interpretable data demonstrating laryngeal obstruction in patients with suspected E-ILO that is more severe at peak work capacity than during rest, submaximal exercise, or recovery. Observed maximal obstruction was infrequently severe and rapidly resolved.

Inducible laryngeal obstruction during exercise: moving beyond vocal cords with new insights

Exercise as an important part of life for the health and wellness of children and adults. Inducible laryngeal obstruction (ILO) is a consensus term used to describe a group of disorders previously called vocal cord dysfunction, paradoxical vocal fold motion, and numerous other terms. Exercise-ILO can impair one's ability to exercise, can be confused with asthma, leading to unnecessary prescription of asthma controller and rescue medication, and results in increased healthcare resource utilization including (rarely) emergency care. It is characterized by episodic shortness of breath and noisy breathing that generally occurs at high work rates. The present diagnostic gold standard for all types of ILO is laryngoscopic visualization of inappropriate glottic or supraglottic movement resulting in airway narrowing during a spontaneous event or provocation challenge. A number of different behavioral techniques, including speech therapy, biofeedback, and cognitive-behavioral psychotherapy, may be appropriate to treat individual patients. A consensus nomenclature, which will allow for better characterization of patients, coupled with new diagnostic techniques, may further define the epidemiology and etiology of ILO as well as enable objective evaluation of therapeutic modalities.