Perceptual Clinical Features in Exercise-Induced Laryngeal Obstruction (EILO): Toward Improved Diagnostic Approaches

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.

Clinical Profiles of Children and Adolescents With Induced Laryngeal Obstruction (ILO) and Exercise Induced Laryngeal Obstruction (EILO)

PURPOSE

To compare clinical profiles of pediatric patients with Induced Laryngeal Obstruction (ILO), Exercise Induced Laryngeal Obstruction (EILO), and EILO with non-exertion related secondary triggers (EILO+).

METHODS

A retrospective observational cohort design was employed. Four-hundred and twenty-three patients <18 years of age were identified from the electronic medical record of a large children's hospital. All patients underwent evaluations with a laryngologist and speech-language pathologist and were diagnosed with EILO/ILO. Patients were divided into 3 groups based on dyspnea triggers reported in initial evaluations. Groups consisted of patients with EILO (N = 281), ILO (N = 30), and EILO+ (N = 112). Patient demographics, EILO/ILO symptoms, endoscopy findings, medical comorbidities, medical history, and EILO/ILO treatment information were extracted and compared across EILO/ILO subtypes.

RESULTS

Patients with EILO experienced higher rates of hyperventilation (P < .001), sore throat (P = .023), and chest pain (P = .003). Patients with ILO were significantly younger in age (P = .017) and presented with increased rates of nighttime symptoms (P < .001), globus sensation (P = .008), self-reported reflux symptoms (P = .023), and history of gastrointestinal conditions (P = .034). Patients with EILO+ were more likely to be female (P = .037) and presented with higher prevalence of anxiety (P = .003), ADHD (P = .004), chest tightness (P = .030), and cough (P < .001).

CONCLUSIONS

Patients with EILO, ILO, and EILO+ present with overlapping but unique clinical profiles. A prospective study is warranted to determine the etiology of these differences and clarify how the efficacy of EILO, ILO, and EILO+ treatment can be maximized.

LEVEL OF EVIDENCE

4.

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.

Exercise-Induced Dyspnea in Collegiate Athletes: Are We Missing the Diagnosis?

OBJECTIVES

Exercise-induced dyspnea (EID) can disrupt an athlete's participation and performance in their given sport. Differential diagnosis of EID is often completed using subjective report and may be inaccurate, therefore increasing the frustration and stress of the athlete. This nonexperimental research study was used to determine prevalence of EID and related respiratory symptoms in athletes at a small, Division I university.

METHODS

An anonymous survey was provided to athletes at Murray State University as they registered for participation in sports for the 2020-2021 school year. Data from this survey was analyzed as to reported physician-given diagnosis of a respiratory disorder as well as reported symptoms of EID.

RESULTS

Results showed that athletes with a physician-given diagnosis often did not report symptoms or responses to medications that support that diagnosis. Additionally, athletes frequently reported symptoms of EID without a formal diagnosis of a respiratory disorder.

CONCLUSIONS

These findings provide preliminary insight and pilot data that may be used to understand the prevalence of EID in collegiate athletes and the need for improved methods of diagnosis for etiologies of EID.

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.

Diagnostic work-up of exercise-induced laryngeal obstruction

PURPOSE

Exercise-induced laryngeal obstruction (EILO) is suspected when dyspnea associated with upper airway symptoms is triggered by exercise. This condition affects mainly adolescent athletes. Visualization of the obstruction, while the patient is experiencing the symptoms during continuous laryngoscopy during exercise (CLE-test) is the gold standard for diagnosing EILO. Our study aims to evaluate the prevalence of EILO in a population presenting exercise-induced inspiratory symptoms (EIIS) or uncontrolled asthma with exertional symptoms. The second objective was to evaluate the diagnostic strength of laryngology consultation (LC) and pulmonary function tests (PFTs).

METHODS

All patients referred to our center for EIIS or uncontrolled asthma with exertional symptoms were included. EILO diagnosis was made if Maat score was > 2 for patients with CLE-test or if there were inspiratory anomalies on PFTs and LC. The sensitivity and specificity of LC and PFTs as diagnostic tools were calculated considering CLE-test as the gold standard.

RESULTS

Sixty two patients were referred to our center for EIIS or uncontrolled asthma with exertional symptoms. EILO was diagnosed in 28 patients (56%) with associated asthma in 9 patients (18%). The sensibility and specificity of LC for supraglottic anomalies were 75% and 60%, respectively. The sensibility and specificity of PFTs were 61% and 89%, respectively.

CONCLUSIONS

There was a high prevalence of EILO among patients with EIIS and uncontrolled asthma. Some clinical characteristics might guide the diagnosis. Nevertheless, CLE-test remained the gold standard for EILO diagnosis and identification of the dysfunctional upper airway site to provide specific management.

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.