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Alanazi A, Aizouki C, Sloychuk J, Callaghan A, Eksteen E, Ennis S, Isaac A. Optimizing the Diagnosis and Management of Pediatric Inducible Laryngeal Obstruction. Laryngoscope 2024. [PMID: 39367750 DOI: 10.1002/lary.31818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 08/28/2024] [Accepted: 09/17/2024] [Indexed: 10/07/2024]
Abstract
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.
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Affiliation(s)
- Alaa Alanazi
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Carolin Aizouki
- Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Janelle Sloychuk
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Amy Callaghan
- Division of Pediatric Surgery, Stollery Children's Hospital, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Eduard Eksteen
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Division of Pediatric Surgery, Stollery Children's Hospital, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sheila Ennis
- Department of Rehabilitation Medicine, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Andre Isaac
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Division of Pediatric Surgery, Stollery Children's Hospital, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Fujiki RB, Johnson R, Fujiki AE, Thibeault SL. Effects of Exercise-Induced Laryngeal Obstruction in Adolescents: A Qualitative Study. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:1911-1929. [PMID: 38728156 PMCID: PMC11253634 DOI: 10.1044/2024_ajslp-23-00296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/09/2023] [Accepted: 03/25/2024] [Indexed: 05/12/2024]
Abstract
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.
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Affiliation(s)
| | | | - Amanda Edith Fujiki
- Division of Child and Adolescent Psychiatry, University of Utah School of Medicine, Salt Lake City
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3
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Ohtani M, Kono M, Tamagawa S, Kouda K, Hotomi M. Epiglottic retraction is useful in diagnosis of exercise-induced laryngeal obstruction. Acta Otolaryngol 2024; 144:392-397. [PMID: 39316781 DOI: 10.1080/00016489.2024.2405002] [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: 08/08/2024] [Accepted: 09/11/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) is distinguished as upper airway obstruction accompanied by inspiratory dyspnoea and stridor during highly intensive exercises. Epiglottic retraction in the diagnosis of EILO has not been sufficiently explored. AIMS/OBJECTIVES We highlight the importance of epiglottic retraction in patients with EILO by evaluation by several diagnostic methods for EILO. Consideration of epiglottic retraction may be important for accurate diagnosis of EILO. RESULTS Epiglottic retraction could be observed in three patients by laryngoscopy during heavy breathing and in two patients by continuous laryngoscopy during exercise. Stridor occurred by the forward prolapse of the arytenoids, but not by epiglottic retraction. In comparison with three athletes from other sports, lung volume was significantly greater in four swimmers although it was not different related to depending on the existence of epiglottic retraction. CONCLUSIONS AND SIGNIFICANCE Laryngoscopy during heavy breathing is suggested to be useful to detect the epiglottic retraction, which might be overlooked if only continuous laryngoscopy during exercise is used. Epiglottic retraction was not rare in Japanese swimmers' exercise-induced laryngeal obstruction in our cohort and it might be related to the greater lung volume.
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Affiliation(s)
- Makiko Ohtani
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
| | - Masamitsu Kono
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
| | - Shunji Tamagawa
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
| | - Ken Kouda
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Muneki Hotomi
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
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Ntoumenopoulos G, Andersen T, Hardingham NM. Upper airway assessment and its implications for interventions by respiratory physiotherapists. Physiother Theory Pract 2024; 40:184-189. [PMID: 35904123 DOI: 10.1080/09593985.2022.2106916] [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: 12/29/2021] [Accepted: 07/16/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND When noninvasive interventions such as chest physiotherapy fail, then more aggressive interventions for airway secretion clearance with nasotracheal airway suctioning may be required. Clinicians however have to insert the nasotracheal suction catheter "blindly" and the success of being able to trigger a cough and pass through the vocal folds with a suction catheter is low. CASE DESCRIPTION The patient, a 48-year-old male underwent a heart and lung transplant. Following extubation, the patient developed secretion retention with a weak ineffective cough and swallow and required physiotherapy interventions with frequent "blind" passes of nasotracheal suctioning. OUTCOMES The patient required nasotracheal suction with frequent multiple failed attempts before successful passage of the suction catheter to trigger a cough reflex and clear secretions. A combined physiotherapist and speech and language therapist intervention during fiberoptic endoscopic evaluation of swallow (FEES) was recorded to both evaluate swallow and passage of the suction catheter. The video illustrated the successful passage of a suctioning catheter through the vocal folds leading to an effective cough and airway clearance. DISCUSSION We present a case report demonstrating that it is feasible to visualize the upper airways during nasotracheal suctioning as an objective means to guide the more accurate successful insertion of the suction catheter past the vocal folds. Rather than "blind" placement of nasotracheal suction catheters visualization using transnasal laryngoscopy should be useful to increase chances of passing through the vocal folds.
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Affiliation(s)
| | - Tiina Andersen
- Norwegian Centre of Excellence for Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - Nicola M Hardingham
- Speech Pathology Department, St Vincent's Hospital, Sydney, Australia
- School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia
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Reid L, Hayatdavoodi M. Hypopharyngeal geometry impact on air-induced loads on the supraglottis. Comput Methods Biomech Biomed Engin 2023:1-11. [PMID: 38006388 DOI: 10.1080/10255842.2023.2285723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/15/2023] [Indexed: 11/27/2023]
Abstract
Exercise-induced laryngeal obstruction (EILO) describes paradoxical laryngeal closure during inspiration at high-intensity exercise. It is hypothesised that during intense activity, the air-induced loads on supraglottic walls overcome their internal stiffness, leading to the obstruction. Recent investigations have revealed that the air-induced loads on the supraglottic walls vary nonlinearly with increasing flow rate. It is, however, unclear whether certain geometric configurations of the hypopharynx and larynx may contribute to the predisposition to EILO. This study investigates the influence of hypopharyngeal and laryngeal geometry on upper respiratory tract airflow and air-induced forces. A computational fluid dynamics model is developed to study airflow through larynx. Four real, adult upper respiratory tracts with variable configurations are considered. Two steady, uniform inspiratory flow rates of 60 L/min and 180 L/min are considered. The analysis shows that geometries with a space lateral to the epiglottis (EpiS) and piriform fossae (PF) directs the hypopharyngeal and supraglottic pressure field to remain positive and increase with the flow rate. In geometries with EpiS and PF, pressure differential occurs around the aryepiglottic fold producing a net inward force over the region. The three-fold increase in flow rate induces near ten-fold increases in force over the region which may facilitate the closure. It is concluded that hypopharyngeal anatomy, particularly the piriform fossae, play a significant role in the obstruction of the supraglottic airway and should be considered in research and clinical assessment of EILO.
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Affiliation(s)
- L Reid
- Centre for Anatomy and Human Identification, University of Dundee, Dundee, UK
- Ear, Nose, and Throat Department, Ninewells Hospital and Medical School, Dundee, UK
| | - M Hayatdavoodi
- School of Science and Engineering, University of Dundee, Dundee, UK
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6
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Reid L, Hayatdavoodi M, Majumdar S. Airflow through the supraglottis during inspiration. Comput Methods Biomech Biomed Engin 2023; 26:1462-1477. [PMID: 36094796 DOI: 10.1080/10255842.2022.2121605] [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: 07/12/2022] [Revised: 08/22/2022] [Accepted: 08/29/2022] [Indexed: 11/03/2022]
Abstract
Exercise-induced laryngeal obstruction is a paradoxical laryngeal closure during inspiration at high-intensity exercise, with supraglottic closure being most common. This study develops a model based on the computational fluid dynamics to investigate airflow velocity and pressure and the air-induced loads on the supraglottis at various inspiratory flow rates. It is found that at high flow rates, positive wall pressure is formed in the hypopharynx localise towards its lower region, while posterior supraglottic wall pressures shift from positive to negative. These findings suggest that high inspiratory flow rates may increase supraglottic pressure differentials, ultimately contributing in the collapse.
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Affiliation(s)
- L Reid
- Centre for Anatomy and Human Identification, University of Dundee, Dundee, UK
| | - M Hayatdavoodi
- School of Science and Engineering, University of Dundee, Dundee, UK
| | - S Majumdar
- Ear, Nose, and Throat Department, Ninewells Hospital and Medical School, Dundee, UK
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Irewall T, Bäcklund C, Naumburg E, Ryding M, Stenfors N. A longitudinal follow-up of continuous laryngoscopy during exercise test scores in athletes irrespective of laryngeal obstruction, respiratory symptoms, and intervention. BMC Sports Sci Med Rehabil 2023; 15:87. [PMID: 37454093 DOI: 10.1186/s13102-023-00681-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) is diagnosed by the continuous laryngoscopy during exercise (CLE) test. Whether or how much CLE test scores vary over time is unknown. This study aimed to compare CLE test scores in athletes over time, irrespective of respiratory symptoms and grade of laryngeal obstruction. METHODS Ninety-eight athletes previously screened for EILO were invited for a follow-up CLE test irrespective of CLE scores and respiratory symptoms. Twenty-nine athletes aged 16-27 did a follow-up CLE test 3-23 months after the baseline test. Laryngeal obstruction at the glottic and supraglottic levels was graded by the observer during exercise, at baseline and follow-up, using a visual grade score (0-3 points). RESULTS At baseline, 11 (38%) of the 29 athletes had moderate laryngeal obstruction and received advice on breathing technique; among them, 8 (73%) reported exercise-induced dyspnea during the last 12 months. At follow-up, 8 (73%) of the athletes receiving advice on breathing technique had an unchanged supraglottic score. Three (17%) of the 18 athletes with no or mild laryngeal obstruction at baseline had moderate supraglottic obstruction at follow-up, and none of the 3 reported exercise-induced dyspnea. CONCLUSIONS In athletes with repeated testing, CLE scores remain mostly stable over 3-24 months even with advice on breathing technique to those with EILO. However, there is some intraindividual variability in CLE scores over time. TRIAL REGISTRATION ISRCTN, ISRCTN60543467, 2020/08/23, retrospectively registered, ISRCTN - ISRCTN60543467: Investigating conditions causing breathlessness in athletes.
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Affiliation(s)
- Tommie Irewall
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Catharina Bäcklund
- Unit of Physiotherapy, Östersund Hospital, Region Jämtland Härjedalen, Östersund, Sweden
| | - Estelle Naumburg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Marie Ryding
- Unit of Otorhinolaryngology, Östersund Hospital, Region Jämtland Härjedalen, Östersund, Sweden
| | - Nikolai Stenfors
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
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Giraud L, Destors M, Clin R, Fabre C, Doutreleau S, Atallah I. Diagnostic work-up of exercise-induced laryngeal obstruction. Eur Arch Otorhinolaryngol 2023; 280:1273-1281. [PMID: 36136148 DOI: 10.1007/s00405-022-07654-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/12/2022] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ludovic Giraud
- Otolaryngology-Head and Neck Surgery Department, Clinique Universitaire d'ORL et Chirurgie Cervico-Faciale, CHU Grenoble Alpes, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France.,Faculté́ de Médecine, Université́ Grenoble Alpes, Domaine de la Merci, BP 170, 38042, Grenoble Cedex 9, France
| | - Marie Destors
- Clinique de Physiologie Sommeil et Exercice, CHU Grenoble Alpes, BP 217, 38043, Grenoble Cedex 09, France
| | - Rita Clin
- Clinique de Physiologie Sommeil et Exercice, CHU Grenoble Alpes, BP 217, 38043, Grenoble Cedex 09, France.,Inserm 1042, Laboratoire HP2, Université Grenoble-Alpes, 38000, Grenoble, France.,Pôle Thorax et Vaisseaux, Clinique de Physiologie Sommeil et Exercice, CHU de Grenoble-Alpes, 38000, Grenobl, France
| | - Christol Fabre
- Otolaryngology-Head and Neck Surgery Department, Clinique Universitaire d'ORL et Chirurgie Cervico-Faciale, CHU Grenoble Alpes, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France.,Faculté́ de Médecine, Université́ Grenoble Alpes, Domaine de la Merci, BP 170, 38042, Grenoble Cedex 9, France
| | - Stéphane Doutreleau
- Médecine du Sport, CHU Grenoble Alpes, Hôpital Sud, 19 Avenue de Kimberley, 38130, Échirolles, France
| | - Ihab Atallah
- Otolaryngology-Head and Neck Surgery Department, Clinique Universitaire d'ORL et Chirurgie Cervico-Faciale, CHU Grenoble Alpes, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France. .,Faculté́ de Médecine, Université́ Grenoble Alpes, Domaine de la Merci, BP 170, 38042, Grenoble Cedex 9, France.
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Koh J, Phyland D, Baxter M, Leong P, Bardin PG. Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics. Expert Rev Respir Med 2023; 17:429-445. [PMID: 37194252 DOI: 10.1080/17476348.2023.2215434] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based. AREAS COVERED A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure. EXPERT OPINION Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.
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Affiliation(s)
- Joo Koh
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Debra Phyland
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Malcolm Baxter
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Paul Leong
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
| | - Philip G Bardin
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
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Hammer IJ, Halvorsen T, Vollsaeter M, Hilland M, Heimdal JH, Røksund OD, Clemm HH. Conundrums in the breathless athlete; exercise induced laryngeal obstruction or asthma? Scand J Med Sci Sports 2022; 32:1041-1049. [PMID: 35114031 PMCID: PMC9303344 DOI: 10.1111/sms.14137] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/30/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) are two disorders commonly considered when athletes complain of exertional dyspnea. They are highly different but often confused. We aimed to address this diagnostic challenge and its consequences in elite athletes. METHODS We included all athletes competing at national or international level, referred to our institution for workup for EILO during 2013-2016. We diagnosed EILO from video-recorded laryngoscopy performed during maximal cardiopulmonary treadmill exercise (CLE-test). Symptoms and previous diagnostic evaluations were obtained from referral letters and chart reviews. RESULTS EILO was diagnosed in 73/101 referred athletes, of whom 70/73 had moderate/severe supraglottic obstruction and 3/73 had primarily glottic obstruction with only minor supraglottic involvement. Of the 73 athletes with EILO, we were able to identify objective tests for asthma in 55 participants, of whom 22 had findings supporting asthma. However, 58/73 had used asthma therapy at some time previously, with current use in 28. Only three reported that asthma medication had improved their exercise related breathing problems, two of whom with tests confirming asthma. Treatment for EILO improved breathing problems in all but four. CONCLUSIONS Objective testing verified EILO in most of the referred athletes. EILO coexisting with asthma was common, and large proportions had used asthma medication; however, few reported effect on exercise related breathing problems. Unexplained persistent exertional dyspnoea must not lead to indiscriminate escalation of asthma treatment, but instead incite investigation for EILO, either as a co-morbidity or as a differential diagnosis.
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Affiliation(s)
- Ida Jansrud Hammer
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Norwegian School of Sports Sciences, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Maria Vollsaeter
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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11
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Sandnes A, Andersen T, Clemm HH, Hilland M, Heimdal JH, Halvorsen T, Røksund OD, Vollsæter M. Clinical responses following inspiratory muscle training in exercise-induced laryngeal obstruction. Eur Arch Otorhinolaryngol 2021; 279:2511-2522. [PMID: 34954812 PMCID: PMC8986676 DOI: 10.1007/s00405-021-07214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/03/2021] [Indexed: 11/09/2022]
Abstract
Purpose Exercise-induced laryngeal obstruction (EILO) is relatively common in young people. Treatment rests on poor evidence; however, inspiratory muscle training (IMT) has been proposed a promising strategy. We aimed to assess laryngeal outcomes shortly after IMT, and to compare self-reported symptoms with a control group 4–6 years later. Methods Two groups were retrospectively identified from the EILO-register at Haukeland University Hospital, Norway; one group had received only information and breathing advice (IBA), and another additionally IMT (IBA + IMT). At diagnosis, all participants performed continuous laryngoscopy during exercise (CLE), with findings split by glottic and supraglottic scores, and completed a questionnaire mapping exercise-related symptoms. After 2–4 weeks, the IBA + IMT-group was re-evaluated with CLE-test. After 4–6 years, both groups were re-assessed with a questionnaire. Results We identified 116 eligible patients from the EILO-register. Response rates after 4–6 years were 23/58 (40%) and 32/58 (55%) in the IBA and IBA + IMT-group, respectively. At diagnosis, both groups rated symptoms similarly, but laryngeal scores were higher in the IBA + IMT-group (P = 0.003). After 2–4 weeks, 23/32 in the IBA + IMT-group reported symptom improvements, associated with a decrease of mainly glottic scores (1.7–0.3; P < 0.001), contrasting unchanged scores in the 9/32 without symptom improvements. After 4–6 years, exercise-related symptoms and activity levels had decreased to similar levels in both groups, with no added benefit from IMT; however, full symptom resolution was reported by only 8/55 participants. Conclusion Self-reported EILO symptoms had improved after 4–6 years, irrespective of initial treatment. Full symptom resolution was rare, suggesting individual follow-up should be offered. Supplementary Information The online version contains supplementary material available at 10.1007/s00405-021-07214-5.
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Affiliation(s)
- Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway. .,Institute of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Tiina Andersen
- Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Institute of Surgical Science, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Ola Drange Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Maria Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway
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12
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Vollsæter M, Stensrud T, Maat R, Halvorsen T, Røksund OD, Sandnes A, Clemm H. Exercise Related Respiratory Problems in the Young-Is It Exercise-Induced Bronchoconstriction or Laryngeal Obstruction? Front Pediatr 2021; 9:800073. [PMID: 35047465 PMCID: PMC8762363 DOI: 10.3389/fped.2021.800073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Complaints of breathlessness during heavy exercise is common in children and adolescents, and represent expressions of a subjective feeling that may be difficult to verify and to link with specific diagnoses through objective tests. Exercise-induced asthma and exercise-induced laryngeal obstruction are two common medical causes of breathing difficulities in children and adolescents that can be challenging to distinguish between, based only on the complaints presented by patients. However, by applying a systematic clinical approach that includes rational use of tests, both conditions can usually be diagnosed reliably. In this invited mini-review, we suggest an approach we find feasible in our everyday clinical work.
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Affiliation(s)
- Maria Vollsæter
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway
| | - Trine Stensrud
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Robert Maat
- Department of Otorhinolaryngology, Saxenburgh Medical Center, Hardenberg, Netherlands
| | - Thomas Halvorsen
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Ola Drange Røksund
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Bergen University College, Bergen, Norway
| | - Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Hege Clemm
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway
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13
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Benestad MR, Drageset J, Clemm H, Røksund OD, Vollsæter M, Halvorsen T, Hysing M, Vederhus BJ. Self-Reported Health in Adolescents With Exercise-Induced Laryngeal Obstruction; A Cross-Sectional Study. Front Pediatr 2021; 9:617759. [PMID: 34307244 PMCID: PMC8295467 DOI: 10.3389/fped.2021.617759] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 06/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Exercise-induced laryngeal obstruction (EILO) is common in young people with exertional breathing difficulties. Psychological characteristics have been proposed as underlying contributors; however, the evidence for this is limited. Objectives: Describe self-reported health, self-efficacy, and anxiety symptoms in adolescents with EILO, and address possible associations with EILO subtypes and severity. Methods: Cross-sectional study of 71/180 (39%) adolescents tested for EILO at Haukeland University Hospital during 2014-2016, age range 14-18 years. Validated questionnaires were used to assess general self-rated health, subjective health complaints (Health Behavior in School-aged Children-Symptom Check List; HBSC-SCL), general self-efficacy (GSE), and anxiety symptoms (SCARED). The outcomes were compared with normative data from comparable unselected populations. Results: The HBSC-SCL items for somatic complaints revealed weekly or more often occurrence of headache in 42%, abdominal pain in 30%, backache in 31%, and dizziness in 32%. For psychological complaints, corresponding figures were 26% for feeling low, 43% for irritability or bad mood, 33% for feeling nervous, and 38% for sleep problems. Mean (range) GSE score was 3.13 (2.2-4.0), and reports suggesting anxiety symptoms were rare. The outcomes were in line with normative data from comparable unselected populations. Self-rated health, and scores obtained for HBSC-SCL, GSE, and SCARED were similarly distributed across EILO subtypes and severity. Conclusion: Self-reported health, self-efficacy, and level of anxiety symptoms in adolescents with laryngoscopically confirmed EILO were similar to data obtained in comparable unselected populations, irrespective of EILO subtype and severity. The findings challenge the notion that pediatric EILO is causally related to psychological problems.
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Affiliation(s)
- Merete R Benestad
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jorunn Drageset
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Hege Clemm
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Ola D Røksund
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Norwegian School of Sport Sciences, Oslo, Norway
| | - Mari Hysing
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Bente J Vederhus
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
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14
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Famokunwa B, Sandhu G, Hull JH. Surgical intervention for exercise-induced laryngeal obstruction: A UK perspective. Laryngoscope 2020; 130:E667-E673. [PMID: 31913523 DOI: 10.1002/lary.28497] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/05/2019] [Accepted: 12/12/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Exercise-induced laryngeal obstruction (EILO) is a prevalent cause of exertional breathlessness and wheeze in young individuals. Typically diagnosed using the continuous laryngoscopy during exercise (CLE) test, treatment is largely based on breathing retraining promoting improved laryngeal function. In some cases, these techniques fail to alleviate symptoms, and surgical intervention with supraglottoplasty can be valuable in the supraglottic form of EILO. Globally, there is currently limited experience utilizing a surgical approach to EILO, and data regarding the optimum surgical technique and published outcomes and complication rates are thus limited. STUDY DESIGN Retrospective observational case series. METHODS In this report, we describe our experience as the only UK center undertaking supraglottoplasty for EILO. We report the surgical outcome of 19 patients (n = 16 female), mean age, 29.6 ± 13.1 years, referred for surgery with moderate to severe supraglottic EILO. Follow-up clinic ± CLE was performed within 4 months (median = 6 weeks), and CLE scores were evaluated before and following surgery. RESULTS We found a beneficial effect of surgery on supraglottic CLE scores (median score reducing from 3/3 to 1/3 postoperatively [P < .05] overall) with 79% (n = 15) of patients reporting an improvement in their exercise capacity. One patient developed an apparent increased tendency for glottic-level EILO following surgery; however, no voice- or swallowing-related complications were encountered. CONCLUSIONS This study is the first to report the UK experience, surgical technique, and outcome for EILO surgery. The findings indicate that EILO surgery appears to be a safe and effective option for individuals with moderate to severe supraglottic-type EILO who have failed initial conservative treatment. LEVEL OF EVIDENCE 5 Laryngoscope, 130:E667-E673, 2020.
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Affiliation(s)
- Bamidele Famokunwa
- North Bristol Lung Centre, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Guri Sandhu
- Department of Laryngology, Charing Cross Hospital London, London, United Kingdom
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
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15
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Barker N, Thevasagayam R, Ugonna K, Kirkby J. Pediatric Dysfunctional Breathing: Proposed Components, Mechanisms, Diagnosis, and Management. Front Pediatr 2020; 8:379. [PMID: 32766182 PMCID: PMC7378385 DOI: 10.3389/fped.2020.00379] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
Dysfunctional breathing (DB) is an overarching term describing deviations in the normal biomechanical patterns of breathing which have a significant impact on quality of life, performance and functioning. Whilst it occurs in both children and adults, this article focuses specifically on children. DB can be viewed as having two components; breathing pattern disorder (BPD) and inducible laryngeal obstruction (ILO). They can be considered in isolation, however, are intricately related and often co-exist. When both are suspected, we propose both BPD and ILO be investigated within an all-encompassing multi-disciplinary dysfunctional breathing clinic. The MDT clinic can diagnose DB through expert history taking and a choice of appropriate tests/examinations which may include spirometry, breathing pattern analysis, exercise testing and laryngoscopic examination. Use of the proposed algorithm presented in this article will aid decision making regarding choosing the most appropriate tests and understanding the diagnostic implications of these tests. The most common symptoms of DB are shortness of breath and chest discomfort, often during exercise. Patients with DB typically present with normal spirometry and an altered breathing pattern at rest which is amplified during exercise. In pediatric ILO, abnormalities of the upper airway such as cobblestoning are commonly seen followed by abnormal activity of the upper airway structures provoked by exercise. This may be associated with a varying degree of stridor. The symptoms, however, are often misdiagnosed as asthma and the picture can be further complicated by the common co-presentation of DB and asthma. Associated conditions such as asthma, extra-esophageal reflux, rhinitis, and allergy must be treated appropriately and well controlled before any directed therapy for DB can be started if therapy is to be successful. DB in pediatrics is commonly treated with a course of non-pharmaceutical therapy. The therapy is provided by an experienced physiotherapist, speech and language therapist or psychologist depending on the dominant features of the DB presentation (i.e., BPD or ILO in combination or in isolation) and some patients will benefit from input from more than one of these disciplines. An individualized treatment program based on expert assessment and personalized goals will result in a return to normal function with reoccurrence being rare.
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Affiliation(s)
- Nicki Barker
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Ravi Thevasagayam
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Kelechi Ugonna
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Jane Kirkby
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
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16
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Fretheim-Kelly ZL, Halvorsen T, Clemm H, Roksund O, Heimdal JH, Vollsæter M, Fintl C, Strand E. Exercise Induced Laryngeal Obstruction in Humans and Equines. A Comparative Review. Front Physiol 2019; 10:1333. [PMID: 31736771 PMCID: PMC6831747 DOI: 10.3389/fphys.2019.01333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 10/07/2019] [Indexed: 12/03/2022] Open
Abstract
Dynamic obstructions of the larynx are a set of disorders that occur during exercise in equines and humans. There are a number of similarities in presentation, diagnosis, pathophysiology and treatment. Both equines and humans present with exercise intolerance secondary to dyspnea. During laryngoscopy at rest, the larynx appears to function normally. Abnormalities are only revealed during laryngoscopy at exercise, seemingly triggered by increased ventilatory demands, and quickly resolve after cessation of exercise. Lower airway disease (asthma being the most prevalent condition), cardiac disease and lack of fitness are the major differentials in both species. Laryngoscopic examination during exercise should be performed from rest to peak exertion to allow for a comprehensive diagnosis, including where the airway collapse begins, and thereafter how it progresses. Dynamic disorders with most visual similarity between humans and equines are: aryepiglottic fold collapse (both species); equine dynamic laryngeal collapse (DLC) relative to some forms of human combined supraglottic/glottic collapse; and epiglottic retroversion (both species). Quantitative grading techniques, such as airway pressure measurement, that have proven effective in veterinary research are currently being piloted in human studies. Conditions that appear visually similar are treated in comparable ways. The similarities of anatomy and certain types of dynamic collapse would suggest that the equine larynx provides a good model for human upper respiratory tract obstruction during exercise. Thus, close collaboration between veterinarians and medical personal may lead to further advancements in understanding pathophysiologic processes, and enhance the development of improved diagnostic tests and treatments that will benefit both species.
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Affiliation(s)
- Zoe Louise Fretheim-Kelly
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Hege Clemm
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Roksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - John-Helge Heimdal
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Oral Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Constanze Fintl
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
| | - Eric Strand
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
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17
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Sandnes A, Hilland M, Vollsæter M, Andersen T, Engesæter IØ, Sandvik L, Heimdal JH, Halvorsen T, Eide GE, Røksund OD, Clemm HH. Severe Exercise-Induced Laryngeal Obstruction Treated With Supraglottoplasty. Front Surg 2019; 6:44. [PMID: 31417908 PMCID: PMC6684966 DOI: 10.3389/fsurg.2019.00044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/16/2019] [Indexed: 01/29/2023] Open
Abstract
Introduction: Exercise induced laryngeal obstruction (EILO) is relatively common in adolescents, with symptoms often confused with exercise induced asthma. EILO often starts with medial or inward rotation of supraglottic structures of the larynx, whereas glottic adduction appears as a secondary phenomenon in a majority. Therefore, surgical treatment (supraglottoplasty) is used in thoroughly selected and highly motivated patients with pronounced symptoms and severe supraglottic collapse. Aim: To investigate efficacy and safety of laser supraglottoplasty as treatment for severe supraglottic EILO by retrospective chart reviews. Methods: The EILO register at Haukeland University Hospital, Bergen, Norway was used to identify patients who had undergone laser supraglottoplasty for severe supraglottic EILO, verified by continuous laryngoscopy exercise (CLE) test, during 2013–2015. Laser incision in both aryepiglottic folds anterior to the cuneiform tubercles and removal of the mucosa around the top was performed in general anesthesia. Outcomes were questionnaire based self-reported symptoms, and laryngeal obstruction scored according to a defined scheme during a CLE-test performed before and after surgery. Results: Forty-five of 65 eligible patients, mean age 15.9 years, were included. Post-operatively, 38/45 (84%) patients reported less symptoms, whereas CLE-test scores had improved in all, of whom 16/45 (36%) had no signs of obstruction. Most improvements were at the supraglottic level, but 21/45 (47%) also improved at the glottic level. Two of 65 patients had complications; self-limiting vocal fold paresis and scarring/shortening of plica ary-epiglottica. Conclusion: Supraglottoplasty improves symptoms and decreases laryngeal obstruction in patients with severe supraglottic EILO, and appears safe in highly selected cases.
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Affiliation(s)
- Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - Tiina Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway.,Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway
| | | | - Lorentz Sandvik
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege H Clemm
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
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18
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Baxter M, Ruane L, Phyland D, Leahy E, Heke E, Lau KK, Low K, Hamza K, MacDonald M, Bardin PG. Multidisciplinary team clinic for vocal cord dysfunction directs therapy and significantly reduces healthcare utilization. Respirology 2019; 24:758-764. [PMID: 30884033 DOI: 10.1111/resp.13520] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/30/2018] [Accepted: 02/18/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Multidisciplinary team (MDT) clinics use an integrated approach to individualize care of complex medical conditions. Vocal cord dysfunction (VCD) is a challenging condition that is likely to benefit from MDT clinics but this has not been researched. METHODS A prospective observational cohort study of a novel VCD MDT clinic was conducted in patients with suspected VCD. Relevant questionnaires, medical history, physical examination, spirometry, dynamic computerized tomography (CT) larynx and laryngoscopy were utilized and patients were allocated to treatment pathways depending on putative diagnosis. Speech pathology intervention with laryngeal retraining (LR) was offered and if LR therapy failed botulinum toxin injection was offered. Primary outcome was reductions in healthcare utilization. RESULTS Overall, 80 consecutive patients were included in analyses. A definitive diagnosis of VCD was made in 56 of 80 (70%) patients. After LR (n = 35), emergency department (ED)/hospital admissions declined significantly in the subsequent 12 months (P = 0.001). General practice visits also reduced (P < 0.001). Botulinum toxin injections were administered in 21 patients unresponsive to LR therapy and both general practice and ED/hospital visits declined (P < 0.001 and P = 0.01, respectively) after injection. CONCLUSION A multidisciplinary approach to VCD confers benefit and can be used to allocate appropriate management leading to a reduction in healthcare utilization.
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Affiliation(s)
- Malcolm Baxter
- Department Otolaryngology, Head and Neck Surgery, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
| | - Debra Phyland
- Department Otolaryngology, Head and Neck Surgery, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Elizabeth Leahy
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia
| | - Emily Heke
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia
| | - Kenneth K Lau
- Diagnostic Imaging, Monash University and Monash Health, Melbourne, VIC, Australia
| | - Kathy Low
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
| | - Kais Hamza
- Department of Mathematical Sciences, Monash University, Melbourne, VIC, Australia
| | - Martin MacDonald
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
| | - Philip G Bardin
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
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19
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Kolnes LJ, Vollsæter M, Røksund OD, Stensrud T. Physiotherapy improves symptoms of exercise-induced laryngeal obstruction in young elite athletes: a case series. BMJ Open Sport Exerc Med 2019; 5:e000487. [PMID: 30740235 PMCID: PMC6347884 DOI: 10.1136/bmjsem-2018-000487] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE A constricted, upper chest breathing pattern and postural dealignments habitually accompany exercise-induced laryngeal obstruction (EILO), but there are few effective treatments for athletes presenting with EILO. This case series was conducted to examine whether physiotherapy based on principles from the Norwegian psychomotor physiotherapy (NPMP) combined with elements of cognitive behavioural therapy can reduce laryngeal distress in athletes with EILO. METHODS Respiratory distress in four subjects was examined by interview prior to a physiotherapeutic body examination. Inappropriate laryngeal movements during exercise were measured by the continuous laryngoscopy exercise test, lung function was measured by flow-volume curves, and non-specific bronchial hyper-responsiveness was measured by a methacholine provocation test. History of asthma, allergy and respiratory symptoms was recorded in a modified AQUA2008 questionnaire. Parasympathetic activity was assessed by pupillometry. All data were gathered before and after 5 months of intervention. RESULTS Physiotherapy based on the principles from NPMP improved breathing problems in athletes with EILO. All athletes had less respiratory distress, improved lung function at rest and reduced inappropriate laryngeal movements during maximal exercise. CONCLUSION A diaphragmatic breathing pattern, a more balanced tension in respiratory muscles, and sound cervical alignment and stability may help to reduce adverse stress on the respiratory system and optimise the function of the larynx during high-intensity exercise. Our results suggest that understanding and management of EILO need to extend beyond structures located in the anterior neck and include factors influencing the whole respiratory system.
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Affiliation(s)
- Liv-Jorunn Kolnes
- Department of Health and Care Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Maria Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Trine Stensrud
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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20
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Taramarcaz P, Seebach JD, Moetteli L, Benaïm C, Schwitzguebel AJP. Spirometry and provocation tests for vocal fold dysfunction diagnosis: a retrospective case series. Swiss Med Wkly 2019; 148:w14692. [DOI: 10.57187/smw.2018.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIMS
Vocal cord dysfunction (VCD) is characterised by paradoxical inspiratory laryngeal motion and is often misdiagnosed as asthma. Definitive diagnosis of VCD is difficult, because laryngoscopy is positive only during symptomatic episodes or upon provocation with exercise or inhaled irritants. The aims of the study were to better characterise the symptomatology of patients with VCD and to evaluate the potential usefulness of less-invasive diagnostic tools, namely provocation tests and spirometry.
METHODS
Retrospective case series of 84 patients with a typical clinical history of VCD, in whom at least one of the three following diagnostic tests were performed: laryngoscopy, provocation testing, or spirometry.
RESULTS
The mean age of the patients was 51 years and 74% were women. The principal comorbidities were rhinosinusitis (60%), gastro-oesophageal reflux disease (56%) and atopy (54%). Diagnosis of VCD was confirmed in 73/84 cases (87%), by laryngoscopy (8%), spirometry (84%) and/or provocation tests (68%).
CONCLUSIONS
VCD remains an underdiagnosed condition. A negative finding on laryngoscopy can lead to false negative diagnosis if it is done when the patient is asymptomatic. Here we show that a clinical suspicion of VCD, evoked by medical history, can be confirmed in many cases by less invasive diagnostic tools such as spirometry and provocation tests. Future well-conducted prospective case-control studies are needed to draw firmer conclusions and to improve the diagnostic accuracy of this condition.
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21
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Olin JT. Exercise-Induced Laryngeal Obstruction: When Pediatric Exertional Dyspnea Does not Respond to Bronchodilators. Front Pediatr 2019; 7:52. [PMID: 30881950 PMCID: PMC6405419 DOI: 10.3389/fped.2019.00052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/07/2019] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
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22
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Connett GJ, Thomas M. Dysfunctional Breathing in Children and Adults With Asthma. Front Pediatr 2018; 6:406. [PMID: 30627527 PMCID: PMC6306426 DOI: 10.3389/fped.2018.00406] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/07/2018] [Indexed: 12/01/2022] Open
Abstract
Asthma occurs across the life course. Its optimal treatment includes the use of personalized management plans that recognize the importance of co-morbidities including so-called "dysfunctional breathing." Such symptoms can arise as a result of induced laryngeal obstruction (ILO) or alterations in the mechanics of normal breathing called breathing pattern disorders. Whilst these two types of breathing abnormalities might be related, studies tend to focus on only one of them and do not consider their relationship. Evidence for these problems amongst childhood asthmatics is largely anecdotal. They seem rare in early childhood. Both types are more frequently recognized in the second decade of life and girls are affected more often. These observations tantalizingly parallel epidemiological studies characterizing the increasing prevalence and severity of asthma that also occurs amongst females after puberty. Exercise ILO is more common amongst adolescents and young adults. It should be properly delineated as it might be causally related to specific treatable factors. More severe ILO occurring at rest and breathing pattern disorders are more likely to be occurring within a psychological paradigm. Dysfunctional breathing is associated with asthma morbidity through a number of potential mechanisms. These include anxiety induced breathing pattern disorders and the enhanced perception of subsequent symptoms, cooling and drying of the airways from hyperventilation induced hyperresponsiveness and a direct effect of emotional stimuli on airways constriction via cholinergic pathways. Hyperventilation is the most common breathing pattern disorder amongst adults. Although not validated for use in asthma, the Nijmegen questionnaire has been used to characterize this problem. Studies show higher scores amongst women, those with poorly controlled asthma and those with psychiatric problems. Evidence that treatment with breathing retraining techniques is effective in a primary care population including all types of asthmatics suggests the problem might be more ubiquitous than just these high-risk groups. Future challenges include the need for studies characterizing all types of dysfunctional breathing in pediatric and adult patient cohorts and clearly defined, age appropriate, interventional studies. Clinicians caring for asthmatics in all age groups need to be aware of these co-morbidities and routinely ask about symptoms that suggest these problems.
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Affiliation(s)
- Gary J. Connett
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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23
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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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24
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Kolnes LJ, Stensrud T. Exercise-induced laryngeal obstruction in athletes: Contributory factors and treatment implications. Physiother Theory Pract 2018; 35:1170-1181. [PMID: 29757061 DOI: 10.1080/09593985.2018.1474306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
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.
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Affiliation(s)
- Liv-Jorunn Kolnes
- Faculty of Health Sciences, Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,Department of health, Norwegian Institute of Sports Medicine, Oslo, Norway
| | - Trine Stensrud
- Department of Sports medicine, The Norwegian School of Sport Sciences, Oslo, Norway
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25
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Soares M, Rodrigues A, Morais-Almeida M. Inducible Laryngeal Obstruction in the Paediatric Population – Review of the Literature and Current Understanding. ACTA ACUST UNITED AC 2018. [DOI: 10.17925/erpd.2018.4.1.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Inducible laryngeal obstruction (ILO) is a complex entity and its exact mechanisms are still unclear. It is characterised by transient and reversible narrowing of the larynx in response to external triggers, resulting in symptoms such as cough, dyspnoea and noisy breathing. The prevalence of this condition in adult or paediatric populations is uncertain. Management of ILO starts by establishing an accurate diagnosis, and treatment includes control of trigger factors, breathing and relaxation techniques, and speech and respiratory therapy. The aim of this article is to summarise current understanding and provide a review of the literature of ILO in the paediatric population.
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26
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Fretzayas A, Moustaki M, Loukou I, Douros K. Differentiating vocal cord dysfunction from asthma. J Asthma Allergy 2017; 10:277-283. [PMID: 29066919 PMCID: PMC5644529 DOI: 10.2147/jaa.s146007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vocal cord dysfunction (VCD)-associated symptoms are not rare in pediatric patients. Dyspnea, wheezing, stridor, chest pain or tightness and throat discomfort are the most commonly encountered symptoms. They may occur either at rest or more commonly during exercise in patients with VCD, as well as in asthmatic subjects. The phase of respiration (inspiration rather than expiration), the location of the wheezing origin, the rapid resolution of symptoms, and the timing occurring in relation to exercise, when VCD is exercise induced, raise the suspicion of VCD in patients who may have been characterized as merely asthmatics and, most importantly, had not responded to the appropriate treatment. The gold standard method for the diagnosis of VCD is fiberoptic laryngoscopy, which may also identify concomitant laryngeal abnormalities other than VCD. However, as VCD is an intermittent phenomenon, the procedure should be performed while the patient is symptomatic. For this reason, challenges that induce VCD symptoms should be performed, such as exercise tests. Recently, for the evaluation of patients with exercise-induced VCD, continuous laryngoscopy during exercise (such as treadmill, bicycle ergometer, swimming) was used. A definite diagnosis of VCD is of importance, especially for those patients who have been erroneously characterized as asthmatics, without adequate response to treatment. In these cases, another therapeutic approach is necessary, which will depend on whether they suffer solely from VCD or from both conditions.
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Affiliation(s)
- Andrew Fretzayas
- Third Department of Pediatrics, Athens University Medical School, "Attikon" University Hospital, Haidari, Greece.,Athens Medical Center, Department of Pediatrics, Marousi, Greece
| | - Maria Moustaki
- Department of Cystic Fibrosis, "Aghia Sofia", Children's Hospital, Athens, Greece
| | - Ioanna Loukou
- Department of Cystic Fibrosis, "Aghia Sofia", Children's Hospital, Athens, Greece
| | - Konstantinos Douros
- Respiratory Unit, Third Department of Pediatrics, Athens University Medical School, "Attikon" University Hospital, Haidari, Greece
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27
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Walsted ES, Hull JH, Hvedstrup J, Maat RC, Backer V. Validity and reliability of grade scoring in the diagnosis of exercise-induced laryngeal obstruction. ERJ Open Res 2017; 3:00070-2017. [PMID: 28765826 PMCID: PMC5532755 DOI: 10.1183/23120541.00070-2017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 11/05/2022] Open
Abstract
The current gold-standard method for diagnosing exercise-induced laryngeal obstruction (EILO) is continuous laryngoscopy during exercise (CLE), with severity classified by a visual grade scoring system. We evaluated the precision of this approach, by evaluating test-retest reliability of CLE and both inter- and intra-rater variability. In this prospective case-control study, subjects completed four consecutive treadmill CLE tests under identical conditions. Laryngoscopic video recordings were anonymised and graded by three expert raters. 2 months following initial scoring, videos were re-randomised and rating repeated to assess intra-rater agreement. 20 subjects (16 cases and four controls) completed four CLE tests. The time to exhaustion increased by 30 s (95% CI 0.02-57.8, p<0.05) in the second CLE compared with the first test, but remained identical in the subsequent tests. Only one-third of subjects retained their initial diagnosis in the subsequent three tests. Inter-rater agreement on grade scores (weighted Cohen's ϰ) was 0.16-0.45, while intra-rater agreement ranged from 0.30 to 0.67. The CLE test is key in the diagnostic assessment of patients with EILO. However, the widely adopted visual grade scoring system does not appear to be a robust means for reliably classifying severity of EILO.
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Affiliation(s)
- Emil Schwarz Walsted
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark.,Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Jeppe Hvedstrup
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | - Vibeke Backer
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
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28
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Walsted ES, Swanton LL, van van Someren K, Morris TE, Furber M, Backer V, Hull JH. Laryngoscopy during swimming: A novel diagnostic technique to characterize swimming-induced laryngeal obstruction. Laryngoscope 2017; 127:2298-2301. [PMID: 28236311 DOI: 10.1002/lary.26532] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/16/2016] [Accepted: 01/06/2017] [Indexed: 11/07/2022]
Abstract
Exercise-induced laryngeal obstruction (EILO) is a key differential diagnosis for respiratory symptoms in athletes and is particularly prevalent in aquatic athletes. A definitive diagnosis of EILO is dependent on laryngoscopy, performed continuously, while an athlete engages in the sport that precipitates their symptoms. This report provides the first description of the feasibility of performing continuous laryngoscopy during exercise in a swimming environment. The report describes the methodology and safety of the use of continuous laryngoscopy while swimming. Laryngoscope, 127:2298-2301, 2017.
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Affiliation(s)
- Emil S Walsted
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom.,Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Laura L Swanton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Ken van van Someren
- GSK Human Performance Lab, GSK Consumer Healthcare, Brentford, United Kingdom
| | - Tessa E Morris
- GSK Human Performance Lab, GSK Consumer Healthcare, Brentford, United Kingdom
| | - Matthew Furber
- GSK Human Performance Lab, GSK Consumer Healthcare, Brentford, United Kingdom
| | - Vibeke Backer
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
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