Exercise-induced laryngospasm of emotional origin

Eucapnic voluntary hyperpnoea and exercise-induced vocal cord dysfunction

INTRODUCTION

Exercise-induced bronchoconstriction (EIB) is a common condition in endurance athletes. Exercise-induced vocal cord dysfunction (EIVCD) is a frequent confounder of EIB. The diagnosis of EIVCD may be challenging and can be missed as the problem is often intermittent and may only occur during intense exercise. Eucapnic voluntary hyperventilation (EVH) is the best test to detect EIB. This pilot study aimed to assess if EVH could be helpful in the diagnosis of EIVCD associated or not to EIB in athletes.

METHODS

A nasolaryngoscopy was performed during a 6 min EVH test, in 13 female athletes suspected to have VCD, aged 21±7 years. Image analysis was conducted by two Ear Nose and Throat surgeons in random order.

RESULTS

During the EVH, three athletes showed incomplete paradoxical vocal cords movement, without inspiratory stridor. However, 12 athletes showed marked supraglottic movement without inspiratory stridor. In two athletes, this supraglottic movement was severe, one showing a marked collapse of the epiglottis with an almost complete obstruction of the larynx by the arytenoid cartilage mucosa. In 3 of the 12 athletes with supraglottic movement, severe vibration of the mucosa covering the arytenoid cartilages was also observed.

CONCLUSIONS

EVH challenge in athletes can provide information on various types of glottic and supraglottic obstruction in reproducing laryngeal movements during hyperventilation. Our findings make us suggest that exercise induced upper airway obstructions should be named: Exercise-induced laryngeal obstruction (EILO). Then, EILO should be divided in three categories: supraglottic, glottic (EIVCD) and mixed (glottic and supraglottic) obstruction.

ERS/ELS/ACCP 2013 international consensus conference nomenclature on inducible laryngeal obstructions

Individuals reporting episodes of breathing problems caused by re-occurring variable airflow obstructions in the larynx have been described in an increasing number of publications, with more than 40 different terms being used without consensus on definitions. This lack of an international consensus on nomenclature is a serious obstacle for the development of the area, as knowledge from different centres cannot be matched, pooled or readily utilised by others. Thus, an international Task Force has been created, led by the European Respiratory Society/European Laryngological Society/American College of Chest Physicians. This review describes the methods used to reach an international consensus on the subject and the resulting nomenclature, the 2013 international consensus conference nomenclature.

Glottic configuration in patients with exercise-induced stridor: a new paradigm

OBJECTIVES/HYPOTHESIS

Paradoxical vocal fold motion and exercise-induced paradoxical vocal fold motion (EIPVFM) are two related conditions that do not have definitive diagnostic criteria. Much of the EIPVFM literature describes patients with characteristic physiologic findings of severe upper airway obstruction or obvious airflow limitation in the clinical context of exertional dyspnea with audible stridor. The objective of this study was to highlight a group of patients who demonstrate important clinical findings of EIPVFM (exertional dyspnea with audible stridor) without simultaneously definitive physiologic findings (mild glottic adduction and normal flow volume loops).

STUDY DESIGN

Retrospective medical record review.

METHODS

We reviewed the records of 150 patients who performed continuous laryngoscopy during exercise for inclusion in a case series. We excluded patients for technical (incomplete records) and physiologic (extremes of disease severity) reasons. Three blinded physicians (practicing in laryngology, pulmonology, and allergy/immunology) independently evaluated isolated audio tracks, video tracks, and flow volume loops of the remaining patients for the presence or absence of stridor, the glottic configuration, and the presence or absence of inspiratory limitation on exercise flow volume loops at peak work capacity.

RESULTS

Exercise laryngoscopy and flow volume loops were fully evaluated for 23 patients. Five patients with exertional dyspnea were unanimously described as having audible stridor, open glottic configuration, and normal flow volume loops.

CONCLUSIONS

EIPVFM can occur in the absence of widely recognized confirmatory physiologic measures. Improved quantitative metrics are needed to better characterize patients with EIPVFM.

LEVEL OF EVIDENCE

4.

Diagnostic criteria for the classification of vocal cord dysfunction

Vocal cord dysfunction (VCD) is a syndrome characterized by paroxysms of glottic obstruction due to true vocal cord adduction resulting in symptoms such as dyspnea and noisy breathing. Since first described as a distinct clinical entity in 1983, VCD has inadvertently become a collective term for a variety of clinical presentations due to glottic disorders. Despite an increased understanding of laryngeal function over the past 25 years, VCD remains a poorly understood and characterized entity. Disparities in the literature regarding etiology, pathophysiology, and management may be due to the historic approach to this patient population. Additionally, disorders clearly not due to paroxysms of true vocal cord adduction, such as laryngomalacia, vocal cord paresis, and CNS causes, need to be differentiated from VCD. Although a psychologic origin for VCD has been established, gastroesophageal reflux disease (GERD), nonspecific airway irritants, and exercise have also been associated with intermittent laryngeal obstruction with dyspnea and noisy breathing. VCD has been repeatedly misdiagnosed as asthma; however, the relationship between asthma and VCD is elusive. There are numerous case reports on VCD, but there is a paucity of prospective studies. Following an in-depth review of the medical literature, this article examines the available retrospective and prospective evidence to present an approach for evaluation of VCD including: (1) evaluation of factors associated with VCD, (2) differential diagnosis of movement disorders of the upper airway, and (3) clinical, spirometric, and endoscopic criteria for the diagnosis.

Paradoxical vocal cord motion disorder: past, present and future

Paradoxical vocal cord motion disorder (PVCM), also called vocal cord dysfunction, is an important differential diagnosis for asthma. The disorder is often misdiagnosed as asthma leading to unnecessary drug use, very high medical utilisation and occasionally tracheal intubation or tracheostomy. Laryngoscopy is the gold standard for diagnosis of PVCM. Speech therapy and psychotherapy are considered the cornerstone of management of this disorder. The aim of this article is to increase the awareness of PVCM among doctors, highlighting the main characteristics that distinguish it from asthma and discuss the recent medical achievements and the possible future perspectives related to this disorder.

Exercise-induced stridor due to abnormal movement of the arytenoid area: videoendoscopic diagnosis and characterization of the "at risk" group

We evaluated 4 patients who developed severe, symptomatic stridor during maximal cardiopulmonary exercise testing, all referred due to exercise-related dyspnea. All underwent resting, unsedated transnasal fiberoptic laryngoscopy and had normal findings. Four patients performed repeat maximal exercise testing with fiberoptic laryngoscopy, and they form the basis of this report. They had normal vocal cord motion during exercise, but developed abnormal anterior motion of the arytenoid and aryepiglottic folds only at peak exercise, leading to partial airway obstruction and severe stridor. This report details the workup and characterizes patients at risk for this unusual phenomenon.

Vocal cord dysfunction: don't mistake it for asthma

Vocal cord dysfunction (VCD), with its symptoms of stridor, air hunger, and chest or throat tightness, occurs primarily in active adolescents and young adults and may mimic exercise-induced asthma. Suspicions of VCD will be borne out by a mostly inspiratory stridor, abrupt onset and resolution of symptoms, an unpredictable symptom pattern, and the failure of usual asthma medications to resolve attacks. Laryngoscopy during acute symptoms is the definitive diagnostic tool. Panting can often stop an attack, and preventive treatment consists of patient education, speech therapy, and, when needed, psychological measures.

Vocal cord dysfunction in an asthmatic child: case report

Acute functional narrowing of the glottis frequently leads to an inappropriate diagnosis of asthma. Only 2 cases have been reported of patients with asthma and concomitant vocal cord dysfunction. We present the case of an adolescent boy with asthma, who exhibited a worsening of wheezing and a reduction in peak expiratory flow rate out of proportion to symptoms due to a vocal cord dysfunction.