Laryngeal motion during exercise

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.

Adjustments of non-invasive ventilation and mechanically assisted cough by combining ultrasound imaging of the larynx with transnasal fibre-optic laryngoscopy: a protocol for an experimental study

INTRODUCTION

Application of non-invasive positive airway pressure may provoke laryngeal responses that obstruct the airways, especially in patients with disturbed laryngeal control. To control and adjust for this, transnasal fibre-optic laryngoscopy (TFL) is used to visualise laryngeal movements during therapeutic interventions. Being an invasive procedure, this may be unpleasant for patients. The aim of this study is to evaluate if ultrasound (US) imaging of the larynx may be used as an alternative less invasive diagnostic tool for evaluating the upper airway responses to non-invasive ventilation (NIV) and mechanical insufflation-exsufflation (MI-E).

METHODS AND ANALYSIS

This protocol presents an experimental cross-sectional study of a novel method to study laryngeal responses in adult healthy volunteers (n=30). The participants will be assessed with simultaneous TFL and laryngeal US imaging (anterior and lateral approaches) during NIV and MI-E therapy. Additionally, airflow and pressure signals will be registered during the procedures. The primary outcome is whether laryngeal US is a feasible method to study laryngeal responses and, if so, to compare the laryngeal responses visualised with TFL and US. The participants' perception of the examinations will be recorded. Secondary outcomes include airflow curve shapes and calculated ventilation volumes during the interventions.

ETHICS AND DISSEMINATION

The study has been approved by The Regional Committee for Medical Research Ethics in Norway, and registered in ClinicalTrials.gov. Results will be disseminated through peer-reviewed journals, presentation of scientific abstracts at international medical conventions and oral presentations in relevant medical conventions.

TRIAL REGISTRATION NUMBER

NCT04586855.

Exercise-induced laryngeal obstruction: From clinical examination to continuous laryngoscopy during exercise

The diagnosis of exercise-induced laryngeal obstruction (EILO) should be suspected when exercise triggers inspiratory stridor. EILO is common in adolescent populations and has a significant impact on sports. Identification of laryngeal obstruction during continuous laryngoscopy during exercise (CLE) is the gold standard diagnostic tool for this disorder, which is not widely known in France. The challenge faced by otolaryngologists is to identify, among patients referred by pulmonologists or sports physicians, those with exercise-induced inspiratory symptoms or poorly controlled exercise-induced asthma, in whom a diagnosis of EILO is strongly suspected. Laryngoscopy at rest may reveal a laryngeal, glottic or supraglottic abnormality predictive of obstruction at increased inspiratory airflow. When pulmonary function tests are normal or in the case of failure of treatment of exercise-induced asthma, the otolaryngologist must complete the examination by a CLE test to confirm the diagnosis of EILO and identify the site of obstruction. This examination is well tolerated, minimally invasive and allows identification of the site of airflow obstruction, allowing specific conservative or surgical treatment. This technical note describes in detail clinical examination and CLE testing in patients with suspected EILO.

High prevalence of exercise-induced stridor during Parkrun: a cross-sectional field-based evaluation

BACKGROUND AND OBJECTIVE

The differential diagnosis for exercise-associated breathlessness is broad, however, when a young athletic individual presents with respiratory symptoms, they are most often prescribed inhaler therapy for presumed exercise-induced asthma (EIA). The purpose of this study was therefore to use a novel sound-based approach to assessment to evaluate the prevalence of exertional respiratory symptoms and characterise abnormal breathing sounds in a large cohort of recreationally active individuals.

METHODS

Cross-sectional field-based evaluation of individuals completing Parkrun. PHASE 1: Prerace, clinical assessment and baseline spirometry were conducted. At peak exercise and immediately postrace, breathing was monitored continuously using a smartphone. Recordings were analysed retrospectively and coded for signs of the predominant respiratory noise. PHASE 2: A subpopulation that reported symptoms with at least one audible sign of respiratory dysfunction was randomly selected and invited to attend the laboratory on a separate occasion to undergo objective clinical workup to confirm or refute EIA.

RESULTS

Forty-eight participants (22.6%) had at least one audible sign of respiratory dysfunction; inspiratory stridor (9.9%), expiratory wheeze (3.3%), combined stridor+wheeze (3.3%), cough (6.1%). Over one-third of the cohort (38.2%) were classified as symptomatic. Ten individuals attended a follow-up appointment, however, only one had objective evidence of EIA.

CONCLUSIONS

The most common audible sign, detected in approximately 1 in 10 individuals, was inspiratory stridor, a characteristic feature of upper airway closure occurring during exercise. Further work is now required to further validate the precision and feasibility of this diagnostic approach in cohorts reporting exertional breathing difficulty.

Exercise-Associated Dyspnea and Stridor: Thinking Beyond Asthma

Breathlessness during sport can be caused by various cardiorespiratory conditions, but when associated with stridor, usually arises from an upper airway etiology. The term exercise-induced laryngeal obstruction (EILO) is now used to describe the phenomenon of transient glottic closure occurring in association with physical activity. Exercise-related laryngeal closure is most commonly encountered in athletic individuals and likely affects between 5% and 7% of all young adults and adolescents. The diagnosis of EILO is not always straightforward because features can overlap with exercise-induced asthma/exercise-induced bronchoconstriction. EILO can therefore remain misdiagnosed for years, and most patients receive inappropriate asthma therapy. In contrast with asthma, EILO symptoms are usually most prominent at maximal exercise intensity and resolve quickly on exercise cessation. It is important to recognize that EILO and asthma can coexist in a proportion of athletes. The criterion standard test for diagnosing EILO is continuous laryngoscopy during exercise testing, although eucapnic voluntary hyperpnea testing has also been used. Various surgical or pharmacological interventions can be used to treat EILO, but first-line treatment is breathing technique work. Further research is needed to establish the optimal treatment algorithm, and more work is needed to increase awareness of this important clinical entity.

Differences in laryngeal movements during exercise in healthy and dyspnoeic adolescents

OBJECTIVES

To compare glottic and supraglottic movements in healthy adolescents and adolescents experiencing dyspnoea during strenuous exercise.

METHODS

Using the continuous laryngoscopy exercise (CLE)-test laryngeal movements during exercise were analysed in healthy controls (n = 28) and compared to subjects with exercise induced bronchoconstriction (EIB) (n = 10), exercise induced laryngeal obstruction (EILO) (n = 10) and subjects experiencing exercise-induced dyspnoea without having any of these diagnoses (n = 31). Images from the video recordings were assessed regarding glottic angle, glottic area and supraglottic area using the software measuring tool EILOMEA.

RESULTS

No significant differences were detected between controls, the dyspnoea group without a diagnosis of EIB or EILO and the EIB group regarding glottis angle, glottis area or supraglottic area at maximum effort. All three parameters differed significantly in the EILO group compared to the other groups (p=<0.001). In the group with EILO all but one had supraglottic obstruction (corresponding to a CLE-test score ≥2). Movement of the laryngeal structures, corresponding to a CLE-test score of 1, at glottic and/or supraglottic level was seen in 26 of 35 (74%) of controls, 34 out of 41 (83%) of patients in the dyspnoea group, and in 25 of 38 (66%) of EIB-subjects.

CONCLUSION

Minor movements at both glottic and supraglottic level are equally common in healthy controls as among adolescents with exercise induced dyspnoea without EIB or EILO and adolescents with EIB. Adolescents with EILO had a statistically significant more pronounced supraglottic obstruction than the other groups.

Severe Exercise-Induced Laryngeal Obstruction Treated With Supraglottoplasty

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.

A systematic review of surgical treatment for supraglottic exercise-induced laryngeal obstruction

Objectives

Exercise‐induced laryngeal obstruction (EILO) is a condition causing breathing difficulties and stridor during exercise. The condition has in severe cases been treated surgically with supraglottoplasty. The purpose of this systematic review is to assess the evidence and recommendations for surgical intervention in treating patients with EILO.

Methods

A systematic search was performed in PubMed and Embase to identify relevant studies describing surgical treatment of patients diagnosed with severe EILO. According to eligibility criteria, data were independently extracted by two reviewers. To assess the risk of bias of each included study, the Newcastle‐Ottawa scale (NOS) was used.

Results

The screening process identified 11 observational studies with a total of 75 patients. Findings indicated that many beneficial outcomes are to be found in surgical treatment for EILO. These indications were found both on visual verification of improvement of the laryngeal obstruction during exercise and patient self‐reported symptom severity. The average NOS score (4.3) indicated low level of evidence in the included studies.

Conclusion

Studies reporting effects of surgical treatment of EILO have shown promising results in patients with laryngeal obstruction. However, the heterogeneity of study methodologies and the level of evidence precludes definitive recommendations for or against supraglottoplasty at this time; prospective and methodologically robust studies are now needed.

Level of Evidence

4

Working Towards a Common Transatlantic Approach for Evaluation of Exercise-Induced Laryngeal Obstruction

Exertional dyspnea can be a manifestation of dysfunction in a variety of organ systems. Exercise-induced laryngeal obstruction (EILO), a condition previously known as vocal cord dysfunction and paradoxic vocal fold motion, is defined as inappropriate, reversible narrowing of the larynx during vigorous exercise. EILO is usually characterized by typical symptoms, which nevertheless frequently are confused with those of other conditions, including asthma. Laryngoscopy performed as symptoms evolve from rest to peak exercise is pivotal in patient work-up. Moving forward, laryngoscopy findings that definitively characterize EILO need to be defined as do objective measures that can quantitate absolute laryngeal measurements during exercise.

Exercise-Induced Laryngeal Obstruction-An Overview

Exertional dyspnea is common in health and disease. Despite having known for centuries that breathlessness can arise from the larynx, exercise-induced laryngeal obstruction is a more prevalent condition than previously assumed. This article provides a brief overview of the history, epidemiology, and pathophysiology of exercise-induced laryngeal obstruction.

Exercise inducible laryngeal obstruction: diagnostics and management

Obstruction of the central airways is an important cause of exercise-induced inspiratory symptoms (EIIS) in young and otherwise healthy individuals. This is a large, heterogeneous and vastly understudied group of patients. The symptoms are too often confused with those of asthma. Laryngoscopy performed as symptoms evolve during increasing exercise is pivotal, since the larynx plays an important role in symptomatology for the majority. Abnormalities vary between patients, and laryngoscopic findings are important for correct treatment and handling. The simplistic view that all EIIS is due to vocal cord dysfunction [VCD] still hampers science and patient management. Causal mechanisms are poorly understood. Most treatment options are based on weak evidence, but most patients seem to benefit from individualised information and guidance. The place of surgery has not been settled, but supraglottoplasty may cure well-defined severe cases. A systematic clinical approach, more and better research and randomised controlled treatment trials are of utmost importance in this field of respiratory medicine.

Congenital laryngomalacia is related to exercise-induced laryngeal obstruction in adolescence

OBJECTIVES

Congenital laryngomalacia (CLM) is the major cause of stridor in infants. Most cases are expected to resolve before 2 years of age, but long-term respiratory prospects are poorly described. We aimed to investigate if CLM was associated with altered laryngeal structure or function in later life.

METHODS

Twenty of 23 (87%) infants hospitalised at Haukeland University Hospital during 1990-2000 for CLM without comorbidities and matched controls were assessed at mean age 13 years. Past and current respiratory morbidity was recorded in a questionnaire, and spirometry performed according to standard quality criteria. Laryngoscopy was performed at rest and continuously throughout a maximal treadmill exercise test (continuous laryngoscopy exercise test (CLE-test)), and scored and classified in a blinded fashion according to preset criteria.

RESULTS

In the CLM group, laryngeal anatomy supporting CLM in infancy was described at rest in nine (45%) adolescents. Eleven (55%) reported breathing difficulties in relation to exercise, of whom 7 had similarities to CLM at rest and 10 had supraglottic obstruction during CLE-test. Overall, 6/20 had symptoms during exercise and similarities to CLM at rest and obstruction during CLE-test. In the control group, one adolescent reported breathing difficulty during exercise and two had laryngeal obstruction during CLE-test. The two groups differed significantly from each other regarding laryngoscopy scores, obtained at rest and during exercise (p=0.001 or less).

CONCLUSIONS

CLM had left footprints that increased the risk of later exercise-induced symptoms and laryngeal obstruction. The findings underline the heterogeneity of childhood respiratory disease and the importance of considering early life factors.

Larynx during exercise: the unexplored bottleneck of the airways

Exercise-induced shortness of breath is not uncommon in otherwise healthy young people. Based on the presenting symptoms alone, it is challenging to distinguish exercise-induced asthma (EIA) from exercise-induced obstruction of central airways, sometimes leading to diagnostic errors and inadequate treatment. Central airway obstruction usually presents with exercise-induced inspiratory symptoms (EIIS) during ongoing exercise. EIIS tends to peak towards the end of an exercise session or immediately after its completion, contradicting symptoms of EIA typically peaking 3-15 min after the exercise has stopped. EIIS is usually associated with some form of laryngeal obstruction. Transnasal flexible laryngoscopy performed continuously throughout an incremental exercise test from rest to exhaustion or to intolerable symptoms is usually diagnostic, and also provides information that is important for further handling and treatment. Reflecting the complex anatomy and functional features of the larynx, exercise-induced laryngeal obstruction (EILO) appears to be a heterogeneous condition. Contradicting previous beliefs, recent literature suggests that laryngeal adduction in a majority of cases starts in supraglottic structures and that vocal cord adduction (VCD) most often occurs as a secondary phenomenon. However, EILO is poorly understood and more and better research is needed to unravel causal mechanisms. The evidence base for treatment of EILO is weak. Speech therapy, psychotherapy, biofeedback, muscle training, anticholinergic aerosols have all been applied, as has laser supraglottoplasty. Randomized controlled trials with well-defined and verifiable inclusion and success criteria are required to establish evidence-based treatment schemes.

The Effect of Exercise on Respiratory Resistance in Athletes With and Without Paradoxical Vocal Fold Motion Disorder

PURPOSE

An investigational, portable instrument was used to assess inspiratory (R(i)) and expiratory (R(e)) resistances during resting tidal breathing (RTB), postexercise breathing (PEB), and recovery breathing (RB) in athletes with and without paradoxical vocal fold motion disorder (PVFMD).

METHOD

Prospective, controlled, repeated measures within-subject and between-groups design. Twenty-four teenage female athletes, 12 with and 12 without PVFMD, breathed into the Airflow Perturbation Device for baseline measures of respiratory resistance and for two successive 1-min trials after treadmill running for up to 12 min. Exercise duration and dyspnea ratings were collected and compared across groups.

RESULTS

Athletes with PVFMD had lower than control R(i) and R(e) values during RTB that significantly increased at PEB and decreased during RB. Control athletes' R(e) decreased significantly from RTB to PEB but not from PEB to RB, whereas R(i) did not change from RTB to PEB but decreased from PEB to RB. Athletes without PVFMD ran longer, providing lower dyspnea ratings.

CONCLUSION

Immediately following exercise, athletes with PVFMD experienced increased respiratory resistance that affected their exercise performance. The difference in resting respiratory resistances between groups is intriguing and could point to anatomical differences or neural adaptation in teenagers with PVFMD. The Airflow Perturbation Device appears to be a clinically feasible tool that can provide insight into PVFMD and objective data for tracking treatment progress.

Realistic glottal motion and airflow rate during human breathing

The glottal geometry is a key factor in the aerosol delivery efficiency for treatment of lung diseases. However, while glottal vibrations were extensively studied during human phonation, the realistic glottal motion during breathing is poorly understood. Therefore, most current studies assume an idealized steady glottis in the context of respiratory dynamics, and thus neglect the flow unsteadiness related to this motion. This is particularly important to assess the aerosol transport mechanisms in upper airways. This article presents a clinical study conducted on 20 volunteers, to examine the realistic glottal motion during several breathing tasks. Nasofibroscopy was used to investigate the glottal geometrical variations simultaneously with accurate airflow rate measurements. In total, 144 breathing sequences of 30s were recorded. Regarding the whole database, two cases of glottal time-variations were found: "static" or "dynamic" ones. Typically, the peak value of glottal area during slow breathing narrowed from 217 ± 54 mm(2) (mean ± STD) during inspiration, to 178 ± 35 mm(2) during expiration. Considering flow unsteadiness, it is shown that the harmonic approximation of the airflow rate underevaluates the inertial effects as compared to realistic patterns, especially at the onset of the breathing cycle. These measurements provide input data to conduct realistic numerical simulations of laryngeal airflow and particle deposition.

Test-retest reliability of respiratory resistance measured with the airflow perturbation device

PURPOSE

In this study, the authors aimed to determine reliability of the airflow perturbation device (APD) to measure respiratory resistance within and across sessions during resting tidal (RTB) and postexercise breathing in healthy athletes, and during RTB across trials within a session in athletes with paradoxical vocal fold motion (PVFM) disorder.

METHOD

Prospective, repeated-measures design. The APD measured respiratory resistance during 3 baseline assessments in 24 teenage female athletes, 12 with and 12 without PVFM. Control athletes provided data at rest and following a customized exercise challenge during each of 3 sessions. Intraclass correlation coefficient (ICC) analysis assessed strength of relationships, and repeated-measures analysis of variance assessed differences across trials and sessions.

RESULTS

ICC analyses confirmed strong correlations across RTB trials for inspiratory, expiratory, and mean respiratory resistance in both groups. Inspiratory resistance decreased ~5% between sessions for control participants; expiratory and mean respiratory resistances were stable. Data from control athletes across sessions and following rigorous exercise were strongly correlated when taken at comparable intervals.

CONCLUSIONS

APD-measured respiratory resistance, including separate assessments for the inspiratory and expiratory phases, has strong test-retest reliability during RTB and after exercising. This suggests that the APD is a useful measurement tool for the assessment of airway function in patients suspected of having PVFM.

Validity of a new respiratory resistance measurement device to detect glottal area change

OBJECTIVE

To determine the correlation between respiratory resistance (Rr) values measured with the Airflow Perturbation Device (APD) to laryngoscopic images of glottal area (GA) in feigned paradoxical vocal fold motion (PVFM), also known as vocal cord dysfunction.

HYPOTHESIS

There is a strong inverse relationship between Rr and GA such that laryngeal constriction can be detected and quantified by APD-measured Rr.

STUDY DESIGN

Prospective, single subject study.

METHODS

A healthy adult feigned breathing that was characteristic of PVFM. Rr and GA were simultaneously recorded, synchronized, and analyzed for three complete breathing cycles with significant glottal constriction occurring during inspiration.

RESULTS

Cross-correlation analysis revealed a strong negative correlation (-0.824) between GA and Rr during feigned PVFM breathing such that Rr increased when GA decreased.

CONCLUSION

APD-measured Rr appears to be a viable noninvasive method for diagnostic screening and monitoring of treatment outcomes for individuals presenting with dyspnea related to PVFM.

Exercise induced dyspnea in the young. Larynx as the bottleneck of the airways

BACKGROUND

Exercise induced asthma may symptomatically be difficult to differentiate from exercise related obstruction in the upper airways, sometimes leading to diagnostic confusion and inappropriate treatment. Larynx accounts for a significant fraction of total airway resistance, but its role as a limiting factor for airflow during exercise has been hampered by lack of diagnostic tools. We aimed to study laryngeal function in exercising humans by transnasal laryngoscopy.

METHODS

Continuous video recording of the larynx was performed in parallel with continuous film recording of the upper part of the body and recording of breath sounds in subjects running to respiratory distress or exhaustion on a treadmill.

RESULTS

A successful examination was obtained in 20 asymptomatic volunteers and 151 (91%) of 166 young patients with a history of inspiratory distress or stridor during exercise. At rest, six patients had abnormal laryngeal findings. During exercise, a moderate or severe adduction of laryngeal structures was observed in parallel with increasing inspiratory distress in 113 (75%) patients. In 109 of these, adduction started within supraglottic structures, followed by adduction of the vocal cords in 88. In four patients, laryngeal adduction started in the vocal cords, involving supraglottic structures secondarily in three.

CONCLUSION

Larynx can safely be studied throughout a maximum intensity exercise treadmill test. A characteristic laryngeal response pattern to exercise was visualised in a large proportion of patients with suspected upper airway obstruction. Laryngoscopy during ongoing symptoms is recommended for proper assessment of these patients.

Surgical treatment of exercise-induced laryngeal dysfunction

A method for combined ergo-spirometry and continuous laryngeal inspection during exercise, entitled continuous laryngoscopy exercise test (CLE-test) has been developed in order to study airway obstruction at the laryngeal level during exercise. The aim of the study was to apply the CLE-test on patients experiencing respiratory distress during exercise in order to reveal the usefulness of the CLE-test both as a diagnostic tool in the selection of patients for surgery and in evaluation of treatment effects postoperatively. Until now, 81 patients with a history of exercise-induced stridor have undergone the CLE-test. Ten of these patients were selected for surgical treatment based on the severity of symptoms and their motivation for treatment. All ten patients underwent endoscopic supraglottoplasty (ES), with laser incision in both aryepiglottic folds anterior to the cuneiform cartilages and removal of the mucosa around the top of the tubercles. Each patient was examined by the CLE-test before and 3 months after surgery. Eight patients felt subjectively that their breathing capacity during exercise was improved. When pre- and postoperative ergo-spirometry evaluations were compared, increased peak oxygen consumption was observed in four out of ten patients and better maximal minute ventilation in seven out of ten. Postoperative evaluation of the laryngeal images showed less prominent aryepiglottic folds. The typical adduction of the supraglottic structures concomitant with inspiratory stridor found preoperatively was not present in any of the patients during exercise postoperatively. The ES procedure is an efficient surgical treatment for exercise-induced laryngeal supraglottic obstruction and the CLE-test eases the selection of patients for surgery and facilitates the evaluation of treatment effects.

Continuous laryngoscopy exercise test: a method for visualizing laryngeal dysfunction during exercise

OBJECTIVES/HYPOTHESIS

To assess the diagnostic feasibility and patient acceptance of a new developed diagnostic test for exercise induced upper airway flow limitation.

STUDY DESIGN

Clinical case control study including evaluation of contemporary ergo-spirometry and laryngoscopy continuously performed during exercise.

METHODS

Twelve nonsymptomatic controls and four young females with documented dyspnea and noisy breathing during exercise were studied. All subjects exercised to exhaustion on a treadmill while attached to a fully equipped ergo-spirometry unit and a fiberoptic laryngoscope linked to a video camera and a sound recorder.

RESULTS

The test situation was well tolerated. Two control subjects had a minor inspiratory synchronous medial motion of the aryepiglottic folds without limitation of laryngeal airflow. In the four symptomatic subjects, exercise induced inspiratory synchronous medial motion of the dorsal part of the aryepiglottic folds as well as vocal cord adduction and inspiratory stridor was demonstrated.

CONCLUSION

The continuous laryngoscopy exercise test was easy to perform, well tolerated, and can be implemented in future diagnostic work-up programs of laryngeal dysfunction.

Exercise-induced laryngochalasia: an imitator of exercise-induced bronchospasm

BACKGROUND

Patients with exercise-induced laryngochalasia present with dyspnea and stridor during exercise. Symptoms are due to a subtotal occlusion of the larynx resulting from mucosal edema from the aryepiglottic folds being drawn into the endolarynx.

METHODS

We report on three patients with exercise-induced bronchospasm, refractory to standard therapy.

RESULTS

Spirometry with flow-volume loops revealed truncation of the inspiratory limb. Abnormal movement of the arytenoid region was visualized on laryngoscopy. A diagnosis of exercise-induced laryngochalasia was made.

CONCLUSIONS

Evaluation of laryngeal motion in patients with refractory exercise-induced bronchospasm is important. Surgical correction with laser laryngoplasty is effective in carefully selected cases.