Vocal cord dysfunction and asthma

Effects of Exercise-Induced Laryngeal Obstruction in Adolescents: A Qualitative Study

PURPOSE

The purpose of this study was to examine the influence of exercise-induced laryngeal obstruction (EILO) on adolescents.

METHOD

Twenty patients (< 17 years) diagnosed with EILO participated in this study. Patients completed semistructured interviews examining their experience with the health care system, treatment, and the effects of EILO symptoms on quality of life. Interviews were analyzed using a combination of directed and conventional content analyses. Researchers identified seven overarching themes either prior to or during analysis, and 24 subthemes were inductively identified from patient interviews using open, axial, and selective coding.

RESULTS

On average, patients went 1.9 years between symptom onset and EILO diagnosis. Patients described symptom onset as frightening and confusing. Even after initially reporting symptoms to a medical provider, patients went an average of 10.5 months before diagnosis. Patients perceived that delays in diagnosis prevented efficient management and allowed symptoms to escalate. Patients reported that EILO detrimentally influenced athletic performance, forcing them to pace themselves or cease participation altogether. Social and academic effects of EILO included missed classes, difficulty in physical education courses, and resentment from teammates if athletic performance declined. Both athletes and nonathletes indicated that EILO elicited feelings of fear, frustration, dread, guilt, and embarrassment. Patients reported that therapy with a speech-language pathologist (SLP) effectively addressed symptoms; however, employing rescue breathing techniques was often more difficult than anticipated.

CONCLUSIONS

Physical and emotional sequelae associated with EILO may have widespread influence on patient quality of life. Therapy with an SLP reportedly ameliorated EILO symptoms; however, patients indicated that delayed diagnosis allowed negative effects to intensify prior to treatment.

Diagnostic utility of spirometry for children with induced laryngeal obstruction or chronic non-specific cough

PURPOSE

To determine the diagnostic utility of spirometry in distinguishing children with Induced Laryngeal Obstruction (ILO) or chronic non-specific cough (a.k.a. tic cough) from those with mild or moderate to severe asthma.

METHODS

Retrospective cross sectional design. Children diagnosed with ILO (N = 70), chronic non-specific cough (N = 70), mild asthma (N = 60), or moderate to severe asthma (N = 60) were identified from the electronic medical record of a large children's hospital. Spirometry was completed before ILO, non-specific cough, or asthma diagnoses were made by pediatric laryngologists or pulmonologists. Spirometry was performed following American Thoracic Society guidelines and was interpreted by a pediatric pulmonologist. Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1), FEV1/FVC Ratio (FEV1/FVC), Forced Mid-Expiratory Flow 25--75 % (FEF25-75%), pulmonologist interpretation of flow volume loops, and overall exam findings were extracted from the medical record.

RESULTS

Ninety seven percent of children with ILO or chronic non-specific cough presented with spirometry values within normative range. Patients with ILO, non-specific cough, and mild asthma presented with FVC, FEV1, FEV1/FVC, and FEF25-75% values in statistically similar range. Children with moderate to severe asthma presented with significantly reduced FVC (p < .001), FEV1 (p < .001), FEV1/FVC (p < .001), and FEF25-75% (p < .001) values when compared with patients in the other groups. Flow volume loops were predominantly normal for children with ILO and non-specific cough.

CONCLUSIONS

Findings indicate that ILO and chronic non-specific cough can neither be diagnosed nor differentiated from mild asthma using spirometry alone. Spirometry should therefore be used judiciously with this population, bearing in mind the limitations of the procedure. Future research should determine the most effective and efficient ways of delineating ILO and non-specific cough from other respiratory conditions in children.

Economic Burden of Induced Laryngeal Obstruction in Adolescents and Children

PURPOSE

Diagnosing pediatric induced laryngeal obstruction (ILO) requires equipment typically available in specialist settings, and patients often see multiple providers before a diagnosis is determined. This study examined the financial burden associated with the diagnosis and treatment of ILO in pediatric patients with reference to socioeconomic disadvantage.

METHODS

Adolescents and children (<18 years of age) diagnosed with ILO were identified through the University of Madison Voice and Swallow Outcomes Database. Procedures, office visits, and prescribed medications were collected from the electronic medical record. Expenditures were calculated for two time periods (1) pre-diagnosis (first dyspnea-related visit to diagnosis), and (2) the first year following diagnosis. The Area Deprivation Index (ADI) was used to estimate patient socioeconomic status to determine if costs differed with neighborhood-level disadvantage.

RESULTS

A total of 113 patients met inclusion criteria (13.9 years, 79% female). Total pre-diagnosis costs of ILO averaged $6486.93 (SD = $6604.14, median = $3845.66) and post-diagnosis costs averaged $2067.69 (SD = $2322.78; median = $1384.12). Patients underwent a mean of 3.01 (SD = 1.9; median = 2) procedures and 5.8 (SD = 4.7; median = 5) office visits prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. Patients living in neighborhoods with greater socioeconomic disadvantage underwent fewer procedures and were prescribed more medication than those from more affluent areas. However, total expenditures did not differ based on ADI.

CONCLUSIONS

Pediatric ILO is associated with considerable financial costs. The source of these costs, however, differed according to socioeconomic advantage. Future work should determine how ILO diagnosis and management can be more efficient and equitable across all patients. Laryngoscope, 134:3384-3390, 2024.

A multidimensional strategy to managing dysfunctional breathing and exercise-induced laryngeal obstruction in adolescent athletes

BACKGROUND

Exercise induced laryngeal obstruction (EILO) causes inspiratory distress in the upper airway in many adolescent athletes. The nature of EILO is not fully understood, and effective management strategies are lacking. This study aimed to assess the effectiveness of a multidimensional individually tailored intervention, including Norwegian Psychomotor Physiotherapy (NPMP), elements of cognitive behavioural therapy and a rehabilitation plan, in reducing inspiratory distress and dysfunctional breathing in adolescent athletes with EILO.

METHODS

A mixed methods design, which combined qualitative and quantitative research, was used. Data, including subjective experiences of respiratory distress, findings from body examinations and objective measurements of lung function and aerobic capacity were gathered before and after a five month intervention involving 18 participants.

RESULTS

Following the intervention, the participants showed a reduction in respiratory distress and anxiousness associated with their breathing difficulties. Furthermore, the participants reported to be more in control of their breathing. The body assessments revealed a more functional breathing motion and improved posture, which imply that the breathing was less thoracic and more diaphragmatic in rest and exercise in all participants after the intervention.

CONCLUSIONS

Our results suggest that a multidimensional individually tailored intervention, including NPMP based physiotherapy, cognitive behavioural therapy elements, and a rehabilitation plan may reduce inspiratory distress and dysfunctional breathing in athletes with EILO.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol Registration and Results system NCT06033755, date of registration: September12, 2023. Retrospectively registered.

Examining therapy duration in adults with induced laryngeal obstruction (ILO)

OBJECTIVE

This study examined the number of therapy sessions required to sufficiently improve (exercise) induced laryngeal obstruction (EILO/ILO) symptoms for discharge. Factors predicting therapy duration were examined as was the likelihood of patients returning for additional therapy sessions following initial discharge.

METHODS

Retrospective observational cohort design. Data for 350 patients were gathered from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. Patients (>18 years of age) diagnosed with EILO/ILO received therapy from a Speech-Language Pathologist (SLP) and were successfully discharged. EILO/ILO treatment details, symptoms, triggers, medical comorbidities, and patient demographics were collected from initial evaluations and subsequent course of therapy.

RESULTS

Patients required an average of 3.59 (SD = 3.7) therapy sessions prior to discharge. A comorbid behavioral health diagnosis (p = .026), higher Vocal Handicap Index Score (p = .009) and reduced physical activity due to EILO/ILO symptoms (p = .032) were associated with increased therapy duration. Patients with ILO or EILO with secondary environmental triggers required significantly more sessions than those with exercise-induced symptoms (p < .01). Eight percent of patients returned for additional sessions following discharge. Patients returning for additional sessions all came from affluent neighborhoods as measured by the Area Deprivation Index (ADI).

CONCLUSIONS

Patients with EILO/ILO required an average of 3.59 therapy sessions prior to discharge. As such, 4 sessions is a reasonable estimate for clinicians to provide patients. Six sessions may be a more conservative estimate for patients who present with a behavioral health diagnosis, a voice complaint, or reduced physical activity from EILO/ILO symptoms.

Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction

PURPOSE

This study examined treatment outcomes of speech-language pathology intervention addressing exercise-induced laryngeal obstruction (EILO) symptoms in teenage athletes.

METHOD

A prospective cohort design was utilized; teenagers diagnosed with EILO completed questionnaires during initial EILO evaluations, posttherapy, 3-month posttherapy, and 6-month posttherapy. Questionnaires examined the frequency of breathing problems, the use of the techniques taught in therapy, and the use of inhaler. Patients completed the Pediatric Quality of Life (PedsQL) inventory at all time points.

RESULTS

Fifty-nine patients completed baseline questionnaires. Of these, 38 were surveyed posttherapy, 32 at 3-month posttherapy, and 27 at 6-month posttherapy. Patients reported more frequent and complete activity participation immediately posttherapy (p = .017) as well as reduced inhaler use (p = .036). Patients also reported a significant reduction in the frequency of breathing problems 6-month posttherapy (p = .015). Baseline PedsQL physical and psychosocial scores were below normative range and were not impacted by therapy. Baseline physical PedsQL score significantly predicted frequency of breathing difficulty 6-month posttherapy (p = .04), as better baseline scores were associated with fewer residual symptoms.

CONCLUSIONS

Therapy with a speech-language pathologist for EILO allowed for more frequent physical activity following therapy completion and decreased dyspnea symptoms 6-month posttherapy. Therapy was associated with a decrease in inhaler use. PedsQL scores indicated mildly poor health-related quality of life even after EILO symptoms improved. Findings support therapy as an effective treatment for EILO in teenage athletes and suggest that dyspnea symptoms may continue to improve following discharge as patients continue using therapy techniques.

Stressed and Distressed: Potential Underpinnings of Exercise-Related Inspiratory Distress in Adolescent Sport Performers

Many adolescent sport performers present with exercise-related respiratory symptoms consistent with exercise-induced laryngeal obstruction (EILO). The pathogenic underpinnings of EILO are not fully resolved, and existing behavioral management includes therapies targeting laryngeal physiology whereas surgical interventions target laryngeal anatomical anomalies. Recent findings from research and clinical practice indicate that psychological stress and thoracic breathing co-occur with laryngeal tightness in adolescent sport performers with EILO. This Perspective article theorizes on this potential coexistence. It discusses possible underpinnings of respiratory symptoms (including EILO) and thoracic breathing in adolescent sport performers by considering the effects of various stressors to which adolescent sport performers are exposed, and the impact these may have on the breathing, including in terms of laryngeal narrowing. The effect of stress on the breathing is examined in light of the reciprocal communication between the brain and the body and the relationship between psychological stress and stress responses in the respiratory system mediated by the autonomic nervous system. To inform decision-making and clinical awareness in this area, it may be worth expanding the focus from targeting mainly laryngeal structures to also include constrictions of the airways and the effects of thoracic breathing on the larynx during exercise. The importance of considering respiratory distress from a multidimensional perspective, and of incorporating the complexity of sport performers' psychological and physical experiences in the management of their health and well-being, is emphasized.

IMPACT

This Perspective adds to the understanding of respiratory distress in populations other than adults, which is important and necessary.

LAY SUMMARY

Adolescent sport performers are exposed to a number of stressors that may affect breathing and laryngeal narrowing, which in turn may have implications for the management of their overall health and well-being.

Exercise laryngoscopy in athletes and sportsmen: an easy way to assess exercise-induced laryngeal obstruction

BACKGROUND

Exercise-induced laryngeal obstruction (EILO) is an exercise-dependent dyspnoea, linked to a laryngeal closure during physical effort. It may concern from 5% to 7% of adolescents and young athletic adults. EILO is a quite recently described condition: standardized diagnostic criteria and consensual management are still to come. Formal diagnosis of EILO requires a continuous laryngoscopy during exercise (CLE). This test allows visualization of laryngeal abnormalities during an effort but is only accessible in specialized centres.

AIMS

We wanted to assess performance of a simplified CLE (sCLE) procedure for EILO diagnosis in everyday practice.

MATERIAL AND METHODS

The procedure consisted in a continuous flexible videolaryngoscopy during a cycloergometre cardio-pulmonary exercise test. Screening questionnaire and visual scoring of laryngeal abnormalities were performed. Patients clinically suspected of EILO were included from 2018 to 2020.

RESULTS

Seventeen consecutive subjects had an indication for sCLE. Fifteen patients underwent sCLE, and EILO-linked significative abnormalities were observed in 80% of them, thus confirming the diagnosis.

CONCLUSIONS

CLE can be done successfully in a simple way. Due to its simplicity, tolerance and contribution in EILO diagnosis, this simplified version of CLE may promote its widespread use in ENT and pulmonology practices, as an affordable confirmation test.

[Vocal cord dysfunction in athletes: Interest of rehabilitation to effort]

INTRODUCTION

Vocal Cord Dysfunction (VCD) is a syndrome characterized by paradoxical adduction of the vocal folds during breathing. Its non-specific clinical manifestations frequently lead to misdiagnosis and delay in its treatment. The treatment of VCD is not pharmacological but rehabilitative and remains poorly appreciated.

OBSERVATION

In this clinical case we describe a 16-year-old female judoka who presented with effort intolerance associated with occasional dyspnea, which had suddenly worsened over the preceding few months so that in now produced sudden respiratory difficulty, mainly during intense and sudden efforts. After a period where her symptoms were confused with asthma, she was diagnosed with exercise-induced VCD. Her treatment was aimed to: (a) rehabilitate respiratory mechanics in order to eliminate abdominal-thoracic asynchrony, (b) rehabilitate naso-nasal breathing, (c) train her to control abdominal-diaphragmatic breathing at rest and then during effort, (d) train her to use ventilatory control as soon as prodromal symptoms appear in order to prevent the development of stridor or complete closure of the vocal folds (at rest and then progressively during exercise).

CONCLUSION

Following the implementation of these rehabilitation strategies to correct her ventilatory and dyskinetic issues, the patient no longer develops respiratory discomfort during exercise, including during judo competitions.

Inducible laryngeal obstruction: Endoscopic quantitative analysis of glottic aperture

OBJECTIVES

Using a method developed for this study, the objective was to perform a quantitative analysis of glottic aperture during the respiratory cycle in subjects suspected of having inducible laryngeal obstruction (ILO) and to compare results to healthy individuals. Correlations between glottic aperture and spirometric parameters were assessed.

METHODS

Subjects with high clinical suspicion of ILO and atypical inspiratory findings in spirometry had the images of their laryngoscopy displayed alongside a respiratory flow chart and both were recorded simultaneously. This method allowed detailed analysis of the glottic aperture by measuring the angle of the anterior commissure during inspiration and expiration. Healthy volunteers who performed the same tests and agreed to provide data to this study were used as a control group.

RESULTS

All 15 subjects with ILO and 16 healthy participants were evaluated successfully using the proposed method. Measures of the anterior commissure angle in the ILO versus control group were significantly different in all observed parameters and just three ILO subjects had an anterior commissure closure greater than 50% during the respiratory cycle. Inspired volume (FIF₅₀ ) and mid-vital capacity ratio (FEF₅₀ /FIF₅₀ ) had a significant correlation with glottic aperture parameters when considering the evaluation of the subjects all together.

CONCLUSION

The proposed method provided precise and quantitative analysis of glottic aperture during the respiratory cycle thus indicating that the usage of equipment that allows for such assessment should be encouraged. Also, the threshold of vocal cords closure accepted as indicative of ILO should be reconsidered, especially during the intercritical period of the disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E349-E356, 2020.

Speech and language therapy for management of chronic cough

BACKGROUND

Cough both protects and clears the airway. Cough has three phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far-reaching impact on quality of life. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non-pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considers the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of SLT in this context.

OBJECTIVES

To evaluate the effectiveness of speech and language therapy for treatment of people with unexplained (idiopathic/refractory) chronic cough.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, trials registries, and reference lists of included studies. Our most recent search was 8 February 2019.

SELECTION CRITERIA

We included RCTs in which participants had a diagnosis of UCC having undergone a full diagnostic workup to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included speech and language therapy techniques for UCC.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of 94 records. Two clinical trials, represented in 10 study reports, met our predefined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. We analysed dichotomous data as odds ratios (ORs), and continuous data as mean differences (MDs) or geometric mean differences. We used standard methods recommended by Cochrane. Our primary outcomes were health-related quality of life (HRQoL) and serious adverse events (SAEs).

MAIN RESULTS

We found two studies involving 162 adults that met our inclusion criteria. Neither of the two studies included children. The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months. Similarly, length of sessions varied slightly from one 60-minute session and three 45-minute sessions to four 30-minute sessions. The control interventions were healthy lifestyle advice in both studies.One study contributed HRQoL data, using the Leicester Cough Questionnaire (LCQ), and we judged the quality of the evidence to be low using the GRADE approach. Data were reported as between-group difference from baseline to four weeks (MD 1.53, 95% confidence interval (CI) 0.21 to 2.85; participants = 71), revealing a statistically significant benefit for people receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week four and three months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach we judged the quality of evidence for this outcome to be low.Data were also available for our prespecified secondary outcomes. In each case data were provided by only one study, therefore there were no opportunities for aggregation; we judged the quality of this evidence to be low for each outcome. A significant difference favouring therapy was demonstrated for: objective cough counts (ratio for mean coughs per hour on treatment was 59% (95% CI 37% to 95%) relative to control; participants = 71); symptom score (MD 9.80, 95% CI 4.50 to 15.10; participants = 87); and clinical improvement as defined by trialists (OR 48.13, 95% CI 13.53 to 171.25; participants = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on visual analogue scale of cough severity: -9.72, 95% CI -20.80 to 1.36; participants = 71) and cough reflex sensitivity (capsaicin concentration to induce five coughs: 1.11 (95% CI 0.80 to 1.54; participants = 49) times higher on treatment than on control). One study reported data on adverse events, and there were no adverse events reported in either the therapy or control arms of the study.

AUTHORS' CONCLUSIONS

The paucity of data in this review highlights the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, we could include only two studies in the review. In addition, this review highlights that endpoints vary between published studies.The improvements in HRQoL (LCQ) and reduction in 24-hour cough frequency seen with the PSALTI intervention were statistically significant but short-lived, with the between-group difference lasting up to four weeks only. Further studies are required to replicate these findings and to investigate the effects of SLT interventions over time. It is clear that SLT interventions vary between studies. Further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQoL. We consider these endpoints to be clinically important. It is also important for future studies to report information on adverse events.Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough. Our review identifies the need for further high-quality research, with comparable endpoints to inform robust conclusions.

Physiotherapy improves symptoms of exercise-induced laryngeal obstruction in young elite athletes: a case series

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.

Exercise-induced laryngeal obstruction in athletes: Contributory factors and treatment implications

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.

Diagnosis and treatment of paradoxical vocal fold motion in infants

IMPORTANCE

Paradoxical vocal fold motion (PVFM) is a disorder often misdiagnosed in children presenting with shortness of breath and stridor. In infants, little is known about the clinical course and best approach for treatment of PVFM. This retrospective study assesses the approach to treatment and outcomes for infants with PVFM.

OBJECTIVE

To investigate the clinical course of paradoxical vocal fold motion (PVFM) in infants.

DESIGN

Retrospective review.

SETTING

Tertiary academic medical center.

PARTICIPANTS

Patients less than 2 years of age diagnosed with PVFM were identified and included in the study.

MAIN OUTCOMES AND MEASURES

History, physical exam findings, and clinical course of treatment for patients less than 2 years old with PVFM were reviewed. Findings including those on flexible fiberoptic laryngoscopy (FFL) and subjective assessment by parents and clinicians were compiled for review.

RESULTS

Seven infants were diagnosed with PVFM. All patients were full term at birth, and average age at diagnosis was 7 months. All patients initially presented with inspiratory stridor, and two patients had stertor. Two of seven patients also had a history of reactive airway disease and one with laryngomalacia. Five had a history of reflux. Two of seven patients had weight percentiles at diagnosis lower than the 25th percentile, while the remainder were between 37th and 75th percentiles. Initial voice evaluation revealed stridor in all patients, as well as finding of PVFM on FFL. All patients were started on anti-reflux medication. Average time to resolution of PVFM was 5.9 months after treatment.

CONCLUSIONS

PVFM can be challenging to diagnose in the infant population. PVFM resolves uneventfully with reflux treatment, however, it is unknown whether reflux treatment is essential or if PVFM would spontaneously resolve. The rarity of infantile PVFM mandates formal evaluation and monitoring by a pediatric otolaryngologist.

Drug-Induced Paradoxical Vocal Fold Motion

Vocal cord dysfunction, also known as paradoxical vocal fold motion (PVFM), is a disorder characterized by abnormal vocal cord adduction during inspiration. PVFM is commonly misdiagnosed as asthma because of the similarity of symptoms: cough, wheezing, chest pain, and dyspnea. We present the clinical vignette of a 36-year-old woman with juvenile rheumatoid arthritis and multiple adverse drug reactions who presented with recurrent episodes of unrecognized PVFM during skin testing for drug allergy, omalizumab treatment, and tocilizumab desensitization. Before the diagnosis of PVFM, these episodes were treated as anaphylaxis, including the administration of epinephrine. Once diagnosed and treated for PVFM, the patient did not present any further events and continued treatment for drug allergy. PVFM may be underreported in hypersensitivity reactions because of the similarity to Type 1-mediated respiratory symptoms and comorbid asthma.

The association between substantiated childhood maltreatment, asthma and lung function: A prospective investigation

BACKGROUND

Asthma reflects multiple and likely complex causal pathways. We investigate the possibility that childhood maltreatment is one such causal pathway. Childhood maltreatment can be interpreted as a form of early life adversity and like other life adversities may predict a range of negative health outcomes, including asthma.

METHODS

A total of 3762 young adults (52.63% female) from the Mater Hospital-University of Queensland Study of Pregnancy (MUSP) participated in this study. MUSP is a prospective Australian birth cohort study of mothers consecutively recruited during their first antenatal clinic visit at Brisbane's Mater Hospital from 1981 to 1983. The study followed both mother-child dyads to the age of 21years after birth. Participants reported whether they had been diagnosed by a physician with asthma by the 21-year follow-up. Trained research assistants also performed gender- and height-standardized lung function tests using a Spirobank G spirometer system attached to a laptop computer. We linked this dataset with data obtained from the child protection services and which comprised all substantiated cases of childhood maltreatment in the MUSP cohort. Substantiations of childhood maltreatment included children in an age range of 0-14years.

RESULTS

The experience of any childhood maltreatment, particularly emotional abuse, was independently associated with self-reported physician-diagnosed asthma by the 21-year follow-up. The association was no longer significant after adjustment for a range of confounders and covariates in neglected children. Childhood maltreatment, including multiple events, was not associated with lung function in adjusted models.

CONCLUSIONS

Childhood maltreatment, including emotional abuse, was associated with lifetime ever asthma. This was in contrast to the absence of an association with objective measures of lung function. More research is indicated on the effect of childhood maltreatment on lung function using objective measures. In the meantime, there should be a greater awareness of the potential impact of childhood maltreatment on the potential to develop asthma, as well as of the possibility that asthma in adulthood may precede childhood maltreatment.

Asthma in adolescence: Is there any news?

Asthma is a chronic disease that has a significant impact quality of life, which is particularly important in adolescence. We will discuss aspects of epidemiology, the clinical spectrum, diagnostics, and management of asthma in adolescence. In particular, we will highlight the psychological implications of having asthma during this developmental period. Data published in the past 10 years, since we last reviewed the subject, will be the main focus of this paper. The care of the teenager with asthma should take into account the rapid physical, emotional, cognitive, and social changes that occur during normal adolescence. The diagnostic process may be more difficult since teenagers tend to deny their illness. Thus, both under-diagnosis and under-assessment of asthma severity may lead to under-treatment and potentially avoidable morbidity and even mortality. Conversely, teenagers may be often misdiagnosed as having asthma or their asthma severity may be overestimated leading to inappropriate and sometimes excessive treatment. Educational programs, environmental avoidance measures, proper use of medications along with a skilled approach, and a caring attitude of health providers are all very important for successful management. Pediatr Pulmonol. 2017;52:129-138. © 2016 Wiley Periodicals, Inc.

Vocal cord dysfunction diagnosis may be improved by a screening check list

BACKGROUND

Many patients with vocal cord dysfunction (VCD), with or without asthma, receive inappropriate treatment because they are misdiagnosed as having difficult-to-control asthma alone. We developed a clinical screening check list designed to aid the diagnosis of VCD.

METHODS

A prospective observational study involving 80 patients aged ≥18 years, diagnosed with severe asthma. After anamnesis and physical examination, physicians completed a check list with 6 questions to identify VCD, for which the answer "yes" counted one point. Then patients underwent spirometry and laryngoscopy. On the basis of the laryngoscopic findings, we created three patient groups: VCD (vocal cord adduction during inspiration, n = 14); unconfirmed VCD (inconclusive findings, n = 29); and control (normal findings, n = 37). We attempted to determine whether any of those groups were associated with the responses to individual questions or sets of questions on the check list.

RESULTS

The proportion of affirmative answers to the question "Does pulmonary auscultation reveal wheezing, predominantly in the cervical region, and/or stridor?" was significantly higher for the VCD group than for the other two groups (P = 0.006), notably in elderly patients. The variable "4 or more affirmative answers" was more common in VCD and unconfirmed VCD groups in comparison to controls (P = 0.022).

CONCLUSIONS

A finding of wheezing or stridor on auscultation of the cervical region is suggestive of vocal cord dysfunction, especially in elderly patients, and such dysfunction can be confirmed through laryngoscopy. Our VCD screening check list proved to be useful in the screening of VCD among patients with severe asthma.

Work-associated irritable larynx syndrome

PURPOSE OF REVIEW

The purpose of this study is to review the relevant literature concerning work-associated irritable larynx syndrome (WILS), a hyperkinetic laryngeal disorder associated with occupational irritant exposure. Clinical symptoms are variable and include dysphonia, cough, dyspnoea and globus pharyngeus. WILS is a clinical diagnosis and can be difficult to differentiate from asthma. Treatment options for WILS include medical and behavioural therapy.

RECENT FINDINGS

Laryngeal-centred upper airway symptoms secondary to airborne irritants have been documented in the literature under a variety of diagnostic labels, including WILS, vocal cord dysfunction (VCD), laryngeal hypersensitivity and laryngeal neuropathy and many others. The underlying pathophysiology is as yet poorly understood; however, the clinical scenario suggests a multifactorial nature to the disorder. More recent literature indicates that central neuronal plasticity, inflammatory processes and psychological factors are all likely contributors.

SUMMARY

Possible mechanisms for WILS include central neuronal network plasticity after noxious exposure and/or viral infection, inflammation (i.e. reflux disease) and intrinsic patient factors such a psychological state. Treatment is individualized and frequently includes one or more of the following: environmental changes in the workplace, GERD therapy, behavioural/speech therapy, psychotherapy counselling and neural modifiers.

Ground zero: not asthma at all

Upper airway obstruction is commonly misdiagnosed as asthma. We report on four children with recurrent respiratory symptoms who had been erroneously diagnosed as having asthma and who received anti-asthma medication for several years. The evaluation of spirometry tracing was neglected in all cases. Subglottic stenosis, tracheomalacia secondary to tracheo-esophageal fistula, double aortic arch, and vocal cord dysfunction were suspected by direct inspection of the flow-volume curves and eventually diagnosed. The value of clinical history and careful evaluation of spirometry tracing in children with persistent respiratory symptoms is critically discussed.

A mobile instrumentation platform to distinguish airway disorders

Asthma and chronic obstructive pulmonary disease (COPD) are distinct but clinically overlapping airway disorders which often create diagnostic and therapeutic dilemmas. Current strategies to discriminate these diseases are limited by insensitivity and poor performance due to biologic variability. We tested the hypothesis that a gas chromatograph/differential mobility spectrometer (GC/DMS) sensor could distinguish between clinically well-defined groups with airway disorders based on the volatile organic compounds (VOCs) obtained from exhaled breath. After comparing VOC profiles obtained from 13 asthma, 5 COPD and 13 healthy control subjects, we found that VOC profiles distinguished asthma from healthy controls and also a subgroup of asthmatics taking the drug omalizumab from healthy controls. The VOC profiles could not distinguish between COPD and any of the other groups. Our results show a potential application of the GC/DMS for non-invasive and bedside diagnostics of asthma and asthma therapy monitoring. Future studies will focus on larger sample sizes and patient cohorts.

Transferable skills in the field of speech language pathology

PURPOSE

To highlight new knowledge and technologies that support the transfer of skills generally acquired by speech language pathologists (SLPs) in academic training programs and clinical practice to involvement in the evaluation and management of individuals with disorders such as paradoxical vocal fold movement (PVFM), chronic cough, manifestations of extra-esophageal reflux (EER), esophageal dysphagia and rumination disorder.

RECENT FINDINGS

A range of studies published in the previous year provide data to support SLP involvement in the management of some disorders, including PVFM, chronic cough, and some manifestations of EER, both as providers and as clinical resources for other health professionals. However, little research is available that describes the role of SLPs in management of esophageal dysphagia or rumination disorder.

SUMMARY

Recent research supports the expanded role of the SLP in the interdisciplinary management of PVFM, chronic cough, manifestations of EER, esophageal dysphagia, and rumination. SLP and other health professionals involved in the care of these patients must find a balance between the practical challenges of treating individuals with increasingly complex medical issues and staying abreast of the latest developments in the diagnosis and treatment of these disorders.

Vocal cord dysfunction related to water-damaged buildings

BACKGROUND

Vocal cord dysfunction (VCD) is the intermittent paradoxical adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. Exposure to damp indoor environments is associated with adverse respiratory health outcomes, including asthma, but its role in the development of VCD is not well described.

OBJECTIVE

We describe the spectrum of respiratory illness in occupants of 2 water-damaged office buildings.

METHODS

The National Institute for Occupational Safety and Health conducted a health hazard evaluation that included interviews with managers, a maintenance officer, a remediation specialist who had evaluated the 2 buildings, employees, and consulting physicians. In addition, medical records and reports of building evaluations were reviewed. Diagnostic evaluations for VCD had been conducted at the Asthma and Allergy Center of the Medical College of Wisconsin.

RESULTS

Two cases of VCD were temporally related to occupancy of water-damaged buildings. The patients experienced cough, chest tightness, dyspnea, wheezing, and hoarseness when in the buildings. Spirometry was normal. Methacholine challenge did not show bronchial hyperreactivity but did elicit symptoms of VCD and inspiratory flow-volume loop truncation. Direct laryngoscopy revealed vocal cord adduction during inspiration. Coworkers developed upper and lower respiratory symptoms; their diagnoses included sinusitis and asthma, consistent with recognized effects of exposure to indoor dampness. Building evaluations provided evidence of water damage and mold growth.

CONCLUSION

VCD can occur with exposure to water-damaged buildings and should be considered in exposed patients with asthma-like symptoms.

Vocal cord dysfunction: a frequently forgotten entity

Vocal cord dysfunction (VCD) is a disorder characterized by unintentional paradoxical adduction of the vocal cords, resulting in episodic shortness of breath, wheezing and stridor. Due to its clinical presentation, this entity is frequently mistaken for asthma. The diagnosis of VCD is made by direct observation of the upper airway by rhinolaryngoscopy, but due to the variable nature of this disorder the diagnosis can sometimes be challenging. We report the case of a 41-year old female referred to our Allergology clinics with the diagnosis of asthma. Thorough investigation revealed VCD as the cause of symptoms.

Work-related laryngeal syndromes

PURPOSE OF REVIEW

This review summarizes recent literature regarding the association of nonorganic laryngeal dysfunction with occupational exposures. Laryngeal dysfunction may masquerade as asthma and is an important consideration in patients with work-associated respiratory symptoms.

RECENT FINDINGS

Although there is lack of consensus regarding clinical features, vocal cord dysfunction (VCD) is the most well appreciated form of nonorganic laryngeal dysfunction. There are significant gaps in the literature regarding the occupational epidemiology of laryngeal dysfunction, however, occupational exposures such as upper airway irritants may be associated with the onset of symptoms. Recurrent work-associated laryngeal dysfunction has been described in occupational groups including the military and professional athletes. Recent theories have considered that VCD may be a state of laryngeal hyperresponsiveness associated with both intrinsic and extrinsic factors.

SUMMARY

Laryngeal dysfunction is an important consideration in patients with work-associated respiratory symptoms. Clinicians should have a high index of suspicion, in particular, if symptoms are associated with exposure to a respiratory irritant. Situations of high psychological stress may also be associated with recurrent symptoms. There is a requirement for evidence-based guidelines for the diagnosis and management of laryngeal dysfunction, which should also address work-related factors.

Vocal cord dysfunction in athletes: clinical presentation and review of the literature

Vocal cord dysfunction (VCD) is a syndrome characterized by the intermittent, abnormal paradoxical adduction of the true vocal cords during respiration resulting in variable upper airway obstruction. It is also commonly referred to as paradoxical vocal fold motion disorder. Patients with VCD usually present with intermittent shortness of breath of varying intensity, wheezing, stridor, choking, throat tightness, voice changes, or cough, and these symptoms often resolve quickly after relaxation or cessation of activity. Since first described as a distinct clinical entity in 1983, VCD remains underrecognized and the underlying cause(s) is not fully understood. Several studies suggest psychogenic or laryngeal hyperresponsiveness as possible underlying causes. Although VCD may have many causes, it can be a unique problem, especially in athletes because it often mimics and can be easily mistaken for exercise-induced bronchospasm, which may result in unnecessary medical treatment and delay in diagnosis. A detailed history, physical examination, and pulmonary function tests with flow-volume loops are important for excluding other diagnoses; however, the gold standard method for diagnosing VCD is by observation of the vocal cords with flexible laryngoscopy. The mainstay of treatment includes behavioral management guided by a speech-language pathologist, but optimal therapy often requires a multidisciplinary team involving a variety of specialties, including certified athletic training, pulmonology, otolaryngology, speech-language pathology, gastroenterology, allergy and immunology, and psychology, as appropriate. We reviewed the medical literature for VCD specifically in athletes, and this article discusses in detail the definition, epidemiology, possible pathophysiology, diagnosis, and treatment options.

Somatoform respiratory disorders in children and adolescents-proposals for a practical approach to definition and classification

Somatoform respiratory disorders represent conditions with dysfunctional breathing unexplained by structural abnormalities. This heterogeneous group includes disorders with neural dysregulation of respiration (vocal cord dysfunction) or with dysregulation of the respiratory pattern (hyperventilation, sighing dyspnea), psychogenic disorders such as unjustified anxiety of suffocation, and stereotype conditions such as throat clearing or habit cough. Many symptoms are nonspecific and largely overlap with respiratory disease symptoms of somatic etiology. Most patients will present in a nonspecialized clinical setting. This article provides symptom-based criteria for the definition of somatoform respiratory disorders and their differentiation from somatic disease. Emphasis is put on clinical criteria which can be easily integrated in a routine setting. Owing to the multifaceted etiology of somatoform respiratory disorders therapeutic approaches integrating somatic medicine, respiratory therapy and psychology are crucial. The introduction of defined clinical criteria may facilitate the discrimination of somatoform respiratory disorders from somatic disorders in routine patient encounters and avoid therapeutic detours.