Gasping for a Diagnosis: Pediatric Vocal Cord Dysfunction

Optimizing the Diagnosis and Management of Pediatric Inducible Laryngeal Obstruction

BACKGROUND

Pediatric inducible laryngeal obstruction (ILO) is difficult to diagnose and treat. Patients often undergo multiple specialist referrals, and long-term outcomes are not well reported.

OBJECTIVES

To investigate the patterns of presentation, workup, and management of children who were diagnosed with ILO at the Stollery Children's Hospital.

METHODS

Retrospective review with a prospective cohort of pediatric patients diagnosed with ILO from 2015 to 2023. We collected the demographic data, diagnostic tests, specialist referrals, time to diagnosis, symptom burden, associated comorbidities and aggravating factors, management, and treatment outcomes. A subset of patients was followed prospectively to determine treatment outcomes. A basic descriptive analysis was performed, and factors associated with time to resolution were studied.

RESULTS

Seventy-eight patients met the criteria for inclusion, with 22 completing prospective questionnaires. The average age was 14 years old, and 75% were female. The majority required multiple specialist referrals. The majority were associated with exercise. Thirty-two (41%) patients had a presumed diagnosis of asthma, despite only four pulmonary function tests being consistent with asthma. Abortive breathing exercises were the most commonly employed (95%) and most successful (61%) nonsurgical management technique. Surgery was highly successful in a small cohort of patients. Median time to symptom resolution was 12 months, with 36% reporting symptoms persistent beyond 3 years.

CONCLUSIONS

Pediatric ILO often goes undiagnosed for prolonged periods. Exercise-related symptoms are the most common. Management strategies have varied levels of success and a large proportion of patients have prolonged symptoms despite treatment, as supported by other recent evidence.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Predictors of voice therapy efficacy in vocal cord dysfunction at a tertiary care center

OBJECTIVE

Vocal cord dysfunction is inappropriate adduction of vocal cords during inspiration that causes dyspnea and is commonly mistaken for exercise-induced asthma. To improve diagnostic accuracy, this study aims to identify demographics associated with vocal cord dysfunction and to determine their impact on the efficacy of voice therapy in improving vocal cord function.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care institution between January 2015 and December 2021.

METHODS

184 patients who underwent voice therapy for vocal cord dysfunction were included. The primary outcome was patient self-reported percent improvement of symptoms. The secondary outcome was number of voice therapy treatments.

RESULTS

The mean duration of symptoms was 2 ± 3 years. The mean number of voice therapy treatments was 2.2 ± 1.5. Of the 107 (58.2 %) patients with documented perceived breathing improvement percentages recorded, the mean maximal percent improvement was 72.5 ± 21.5 %. Mean maximal percent improvement of symptoms increased with each voice therapy treatment (p = 0.01). This association remained significant when controlling for comorbid conditions such as allergic rhinitis with postnasal drip, anxiety, asthma, and gastroesophageal reflux disease in multivariate analysis (p = 0.005). Patients with asthma had significantly higher maximum percent breathing improvement compared to those without asthma (p = 0.026). Similarly, patients who played sports had significantly higher maximum percent breathing improvement compared to those who did not (p = 0.022).

CONCLUSION

Patient perceived breathing improvement with voice therapy is higher among those with concomitant asthma and those who play sports. Voice therapy is a safe and effective first line treatment of vocal cord dysfunction even when controlling for comorbid conditions.

Do not forget asthma comorbidities in pediatric severe asthma!

Asthma is the most common chronic respiratory disease in childhood. The long-term goals in managing asthma aim to control symptoms and prevent exacerbations, as well as to reduce side effects of therapy and mortality disease-related. Most of patients have mild to moderate asthma and respond well to standard therapies. However, a minor proportion of children with asthma has severe disease that remains uncontrolled despite optimal adherence to prescribed therapy and treatment of contributory factors, including trigger exposures and comorbidities, which can mimic or worsen asthma and contribute to exacerbations and poor quality of life. Evaluation of comorbidities is fundamental to optimize the management of the disease in a subgroup of patients with poor responder asthma. The overall aim of this article is to describe characteristics of main pediatric severe asthma comorbidities reported in literature, giving clinicians tools to recognize and manage properly these conditions.