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Sundar KM, Stark A, Morris MJ. Laryngeal Dysfunction Manifesting as Chronic Refractory Cough and Dyspnea: Laryngeal Physiology in Respiratory Health and Disease. Chest 2024; 166:171-186. [PMID: 38508333 DOI: 10.1016/j.chest.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 03/22/2024] Open
Abstract
TOPIC IMPORTANCE Laryngeal dysfunction as a cause of chronic refractory cough and episodic dyspnea is often missed, which results in unnecessary testing and delays in diagnosis. Understanding laryngeal roles in breathing and airway protection can help to appreciate the propensity to laryngeal dysfunction with aging, chronic lung disease, and sleep apnea. REVIEW FINDINGS The human larynx is a complex muscular structure that is responsible for multiple roles of breathing, vocalization, coughing, and swallowing. To undertake these activities, the larynx has a high density of sensory and motor innervation. In addition to common embryological origins with the pharynx and esophagus, with which many laryngeal activities are shared, somatomotor and autonomic pathways regulate emotional, cognitive, and complex motor sequence-planning activities within the larynx. Due to its unique location, the larynx is susceptible to infectious and gastroesophageal reflux-related insults. Couple this with key roles in regulation of airflow and mediation of airway protective reflexes, it is not surprising that neuropathic abnormalities and muscle dysfunction frequently develop. The expression of laryngeal dysfunction as hypersensitivity to mechanical, thermal, chemical, and other stimuli leads to exaggerated airway protective reflexes (laryngeal adductor reflex and cough reflex) manifesting as dyspnea and cough. SUMMARY Pulmonologists should incorporate assessment of laryngeal dysfunction during evaluation of chronic refractory cough and dyspnea. Recognition of laryngeal hypersensitivity in the patient with chronic refractory cough can identify patients who may benefit from cough suppression therapies. Similarly, timely identification of inducible laryngeal obstruction may not only resolve episodic dyspnea but lessen the need for unnecessary testing and treatments.
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Affiliation(s)
- Krishna M Sundar
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT.
| | - Amanda Stark
- Department of Otolaryngology-Head & Neck Surgery & Voice Disorders Center, University of Utah, Salt Lake City, UT
| | - Michael J Morris
- Pulmonary & Critical Care Service, Brooke Army Medical Center, JBSA Fort Sam Houston, TX
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Green S, Hicks A, Hilsendager C, Bauer M, Frank GKW. An adolescent girl with signs and symptoms of anaphylaxis and negative immunologic workup: a case report. J Med Case Rep 2020; 14:49. [PMID: 32299506 PMCID: PMC7164209 DOI: 10.1186/s13256-020-02371-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 03/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background The increasing incidence of allergies and allergic reactions among children and adults has become a major public health concern. The etiology of allergic reactions can often be confirmed based on a detailed history and supportive testing. However, there are cases where the underlying factors are more complex and difficult to identify. Case presentation Here we present the case report of a 14-year-old Caucasian girl with weight loss and a 3-year history of reported angioedema culminating in five intensive care unit admissions over the course of 2.5 months. Her initial clinical presentation included hypotension, dyspnea, and reported facial edema, but allergy and immunological workup were negative. A psychiatric workup identified an eating disorder with food restriction, comorbid major depression, obsessive compulsive disorder, and posttraumatic stress disorder. A close collaboration between Adolescent Medicine, Allergy and Immunology, and Psychiatry helped disentangle medical from psychiatric problems, including fluoxetine medication effects, as well as develop a treatment plan that was acceptable to the family. The angioedema was ultimately diagnosed as factitious disorder. Conclusions This patient’s treatment highlights the importance of a multidisciplinary team approach, a multifactorial etiology that needed to be addressed by multiple specialists, and the importance of long-term treatment and support.
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Affiliation(s)
- Sarah Green
- Department of Pediatrics, Section of Adolescent Medicine, Children's Hospital Colorado, 13123 E. 16th Ave, Box 025, Aurora, CO, 80045, USA. .,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Allison Hicks
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, CO, USA
| | - Chelsea Hilsendager
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Maureen Bauer
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, CO, USA
| | - Guido K W Frank
- Department of Psychiatry, University of California San Diego, San Diego, CA, 92121, USA
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Halevi-Katz D, Sella O, Golan H, Banai K, Van Swearingen J, Krisciunas GP, Abbott KV. Buteyko Breathing Technique for Exertion-Induced Paradoxical Vocal Fold Motion (EI-PVFM). J Voice 2019; 35:40-51. [PMID: 31416749 DOI: 10.1016/j.jvoice.2019.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 01/17/2023]
Abstract
PURPOSE The primary purpose of the current study was to determine the usefulness of Buteyko breathing technique (BBT) in reducing dyspnea in patients with one form of Paradoxical Vocal Fold Motion (PVFM), exertion-induced PVFM (EI-PVFM), concomitant with hyperventilation. The secondary purpose was to determine whether BBT had an effect on physiological markers of hyperventilation, as speculated by BBT theory: respiratory tidal minute volume (RTMV), end-tidal carbon dioxide (ETCO2), and resting heart rate (HR). METHODS Using a within-subjects, repeated measures group design, 12 participants with EI-PVFM and hyperventilation underwent 12 weeks of BBT, following an initial no-treatment control condition. Outcome measures of PVFM-dyspnea frequency and severity-and of hyperventilation-HR, RTMV, and ETCO2-were acquired pre- and post-treatment. RESULTS Results showed post-treatment decreases in dyspnea severity, HR, and RTMV, as well as increases in ETCO2. Decreases in dyspnea and RTMV measures remained after correction for alpha inflation. CONCLUSIONS Findings suggest BBT may be useful for some individuals with EI-PVFM and hyperventilation. The high prevalence of hyperventilation in EI-PVFM found in the current study warrants further investigation.
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Affiliation(s)
- Dana Halevi-Katz
- Department of Communication Sciences and Disorders, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel.
| | - Oshrat Sella
- Department of Communication Sciences and Disorders, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
| | - Hadas Golan
- Department of Otolaryngology, Boston Medical Center, Boston, Massachusetts
| | - Karen Banai
- Department of Communication Sciences and Disorders, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
| | - Jessie Van Swearingen
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
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Pasternak K, Thibeault SL. Factors Affecting Initiation of Voice Therapy for Paradoxical Vocal Fold Motion Disorder. J Voice 2019; 34:559-566. [PMID: 30660338 DOI: 10.1016/j.jvoice.2018.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate patient-level predictors of initiation of voice therapy for paradoxical vocal fold motion disorder (PVFM). STUDY DESIGN Prospective outcomes database study. METHODS Patients consented to the University of Wisconsin Voice and Swallow Clinics Outcomes Database between March 2010 and November 2016 who were diagnosed with PVFM and recommended for voice therapy were eligible. Patients who attended at least one voice therapy session were considered to have initiated therapy. Analyzed variables included age, gender, distance to the clinic, insurance status, socioeconomic factors, comorbidity score, spirometry results, presence of asthma and/or dysphonia diagnoses, length of evaluation and evaluation model, and patient scores on the Voice Handicap Index and Generalized Anxiety Disorder 7-item scale. RESULTS One-hundred seventy-eight patients met inclusion criteria. Of these, 118 initiated voice therapy as recommended (66.29%). The majority of patients were female (n = 127; 71.35%). Age was the only factor significantly associated with therapy initiation in both univariate (P = 0.0359) and multivariable (P = 0.0295) analyses, with patients aged 30-39 least likely to attend compared with other age groups. Multivariable analysis also showed that patients evaluated by a speech-language pathologist alone were an estimated three times as likely to initiate therapy compared to patients evaluated by speech-language pathologist and otolaryngologist (ENT) together (P = 0.0407). Other variables were not statistically significant for prediction of therapy initiation. CONCLUSIONS This study suggests that age group and evaluation model are associated with initiation of voice therapy for PVFM. Further study is needed to investigate social-cognitive and quality-of-life factors in predicting therapy initiation.
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Affiliation(s)
- Kevin Pasternak
- Voice and Swallow Clinics, University Hospital, Madison, Wisconsin.
| | - Susan L Thibeault
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
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Shembel AC, Hartnick CJ, Bunting G, Ballif C, Vanswearingen J, Shaiman S, Johnson A, de Guzman V, Verdolini Abbott K. The Study of Laryngoscopic and Autonomic Patterns in Exercise-Induced Laryngeal Obstruction. Ann Otol Rhinol Laryngol 2018; 127:754-762. [PMID: 30187760 DOI: 10.1177/0003489418796524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Adrianna C Shembel
- 1 Department of Otolaryngology, NYU Langone Medical Center, Voice Center, New York, New York, USA.,2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA.,3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher J Hartnick
- 2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA
| | - Glenn Bunting
- 4 Massachusetts Eye and Ear, Voice and Speech Laboratory, Boston, Massachusetts, USA
| | - Catherine Ballif
- 4 Massachusetts Eye and Ear, Voice and Speech Laboratory, Boston, Massachusetts, USA
| | - Jessie Vanswearingen
- 3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Susan Shaiman
- 3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aaron Johnson
- 1 Department of Otolaryngology, NYU Langone Medical Center, Voice Center, New York, New York, USA
| | - Vanessa de Guzman
- 2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA
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