Treatment effectiveness for Vocal Cord Dysfunction in adults and adolescents: A systematic review

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.

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.

Dysfunctional Breathing in Children: A Literature Review

Dysfunctional breathing (DB) describes a respiratory condition that is mainly characterized by abnormal breathing patterns, affecting both children and adults, often leading to intermittent or chronic complaints and influencing physiological, psychological, and social aspects. Some symptoms include breathlessness; dizziness; palpitations; and anxiety, while its classification lies in breathing pattern disorders and upper airway involvement. Its prevalence among the pediatric population varies with a female overrepresentation, while the existence of comorbidities in DB, such as asthma, gastro-esophageal reflux, nasal diseases, and anxiety/depression, frequently leads to misdiagnosis or underdiagnosis and complicates therapeutic approaches. The basic diagnostic tools involve a detailed history, physical examination, and procedures such as structured light plethysmography, cardiopulmonary exercise testing, and laryngoscopy when a laryngeal obstruction is present. The management of DB presumes a multidimensional approach encompassing breathing retraining, disease-specific advice through speech and language therapy in the presence of laryngeal obstruction, psychotherapy for fostering self-efficacy, and surgical therapy in a structural abnormality. The current review was developed to provide a summary of classifications of DB and epidemiological data concerning the pediatric population, comorbidities, diagnostic tools, and therapeutic approaches to enhance the comprehension and management of DB in children.

Growing up with allergies: Transitioning from adolescence to adulthood

Allergic disease management for adolescents and young adults requires consideration of unique psychosocial challenges and opportunities. Erik Erikson's model for the Stages of Psychosocial Development is a useful lens through which we can understand adolescent and young adult experiences with allergic and immunologic disease, particularly with regard to identity and relationship development. It is important to provide anticipatory guidance for patients who are transitioning environments (eg, home to college), with attention to the anxiety-provoking demands for increased responsibility on top of new stressors such as academic and vocational demands. It is critical that health care professionals use an empathetic, shared decision-making approach regarding the emotional impact of allergy on a patient's social engagement. A patient's ability to develop positive lifelong habits is also shaped by their environment's "culture of wellness," and clinicians can encourage habits to promote healthy choices and effective disease management. Social media provides opportunities and challenges as a conduit for both social connection and possible misinformation. Overall, allergic disease management in adolescents and young adults is a "high-risk, high-reward" period of time-and with awareness, anticipation, and proactive action, health care professionals can better serve patients by leveraging this transitional period to promote positive approaches to management of allergies and asthma, trusting relationships, and personal responsibility.

Noninvasive Management of Voice Disorders: An Umbrella Review

OBJECTIVES

The aim of this study was to assess published systematic reviews that discussed noninvasive management of voice disorders. An umbrella review was conducted to collect, organize, and summarize narratively all available pharmacologic and voice therapy interventions.

STUDY DESIGN

Umbrella review of systematic reviews.

METHODS

Pertinent systematic reviews were identified by searching Pubmed/Medline and Embase. A primary screen identified studies related to voice. The second round of screening focused on studies that involved noninvasive management of voice disorders such as pharmacologic or voice therapy interventions. Variables of interest included study design, number of studies included in the review, target population, method of intervention, and outcomes.

RESULTS

Forty-three systematic reviews were eligible and included in the umbrella review. Ten studies focused on pharmacologic interventions, and 33 studies focused on voice therapy. Individual studies included in the systematic reviews ranged from 2-47, with a total of 601 studies overall.

CONCLUSIONS

This study provides a detailed review of all available systematic reviews on noninvasive management of voice disorders. Explored medications included proton pump inhibitors, calcium channel blockers, tricyclic antidepressants, antibiotics, corticosteroids, and hormone replacement. Explored voice therapy techniques included hydration, vocal function exercises, laryngeal manual therapy, respiratory exercise, biofeedback, phonation, coping strategies, and others. This may be utilized to guide therapeutic decision-making and identify current gaps in the literature that may warrant future investigation.

Exploring Factors Impacting Engagement in Speech Pathology Intervention for Inducible Laryngeal Obstruction

AIM

Speech pathology is the first-line treatment for inducible laryngeal obstruction (ILO) and involves behavioral techniques to address symptoms and modify maladaptive laryngeal postures. Benefit from speech pathology is reliant on patients engaging in treatment sessions, regular home practice, and generalizing techniques to everyday activities. There is limited research exploring engagement in speech pathology treatment for ILO, particularly from the patient perspective. This study aimed to explore the experiences of living with ILO and how this experience may impact the way patients engage in speech pathology treatment.

STUDY DESIGN

Qualitative study.

METHODS

Semistructured interviews were completed with seven participants exploring their experiences living with ILO, their diagnostic process and their experiences with speech pathology treatment. Data were analyzed using reflexive thematic analysis to determine shared meanings across participants and themes were developed.

FINDINGS

Three major themes were identified - Life with ILO, Challenges of Speech Pathology Treatment, and What Matters to Me. Patients' reports of living with ILO and interacting with speech pathology suggested that these experiences impacted their readiness to start treatment and persist through the challenges of the treatment. Engagement appeared to be positively associated with significant ILO symptom burden and life impact, confidence in the diagnostic process, recommendation for speech pathology treatment, a tailored intervention by a patient-perceived expert in the field and working in a partnership with the speech pathologist to develop a sense of agency. Patients indicated their engagement was negatively influenced by competing time demands, social embarrassment when using symptom relief techniques and laryngeal exercises, and a low ILO symptom burden and life impact.

CONCLUSION

The reasons behind engagement in speech pathology treatment for ILO appear to be a complex interaction between previous experiences of living with ILO including the diagnostic process and the experience of speech pathology treatment. A patient-centered approach to therapy may help to maximize engagement by exploring readiness and expectations for treatment. The greater understanding of the patient experience provided through this study may allow speech pathologists to devise meaningful ways to maximize engagement in treatment for people with ILO.

Exploring Mental Health in a Pediatric Paradoxical Vocal Fold Motion Sample Using Patient-Reported Outcomes

OBJECTIVE

Paradoxical vocal fold motion (PVFM) is characterized by inappropriate adduction of vocal folds during inspiration causing dyspnea. While anxiety is suspected to be a predisposing factor, incidence has been understudied.

STUDY DESIGNS

Retrospective review.

SETTING

Multidisciplinary PVFM hospital clinic.

METHODS

We used patient-reported outcome measures to examine anxiety and depression in consecutive patients aged 10 to 17 years using Pediatric SFv1.1 Anxiety 8b and Level 2-Depression inventories (parents completed proxy forms). T-scores were classified as normal (none to slight <55) or elevated (mild 55-59.9, moderate 60-69.9, severe >70).

RESULTS

Twenty-three pediatric patients and 20 parents completed surveys. Mean age was 13.74 years. For anxiety, 69.6% of patients and 40% of parents identified elevated levels. For depression, 30.4% of patients and 15% of parents identified elevated levels. Therapy need for the sample was 65.2% (34.8% active in services and 30.4% referred). Child anxiety scores were significantly higher in the therapy need group, U = 17, P = .004.

CONCLUSION

This study of adolescents with PVFM confirmed elevated anxiety and depression scores in 2/3 of the participants. Anxiety likely precedes diagnosis and is a predisposing factor. Referral for individualized intervention targeting anxiety and depression is indicated.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4.

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.

Treatable traits in asthma during pregnancy: a call for a shift towards a precision-based management approach

Asthma is the most common chronic medical condition in pregnancy. Asthma exacerbations in pregnancy are unpredictable, and are associated with adverse maternal and fetal perinatal outcomes such as preterm birth and low birthweight. Goals of asthma management in pregnancy are to establish effective asthma control and prevent exacerbations. Optimising the management of asthma in pregnancy is an important goal of practice and future research.Treatable traits is a precision medicine paradigm proposed for the management of airways diseases, which holistically addresses the complexity and heterogeneity of airways disease. It is an individualised treatment approach that aims to improve outcomes. This makes treatable traits well suited for pregnant women with asthma, who have a high prevalence of obesity, mental health conditions, poor symptom perception and suboptimal asthma management skills including low treatment adherence. These traits are measurable and treatable. In this review, we explore current knowledge on the burden of asthma, maternal and perinatal consequences of asthma during pregnancy, the treatable traits paradigm, the prevalence of treatable traits in pregnant women with asthma, and consider how the treatable traits paradigm can be integrated into the management of asthma in pregnancy.

The treatable traits approach to adults with obstructive airways disease in primary and secondary care

The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.

Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms

OBJECTIVE

Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation.

DESIGN

This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches.

RESULTS

The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed.

CONCLUSION

Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.

Diagnosis of vocal cord dysfunction/inducible laryngeal obstruction: An International Delphi Consensus Study

BACKGROUND

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is characterized by breathing difficulties in association with excessive supraglottic or glottic laryngeal narrowing. The condition is common and can occur independently; however, it may also be comorbid with other disorders or mimic them. Presentations span multiple specialties and misdiagnosis or delayed diagnosis is commonplace. Group-consensus methods can efficiently generate internationally accepted diagnostic criteria and descriptions to increase clinical recognition, enhance clinical service availability, and catalyze research.

OBJECTIVES

We sought to establish consensus-based diagnostic criteria and methods for VCD/ILO.

METHODS

We performed a modified 2-round Delphi study between December 7, 2021, and March 14, 2022. The study was registered at ANZCTR (Australian New Zealand Clinical Trials Registry; ACTRN12621001520820p). In round 1, experts provided open-ended statements that were categorized, deduplicated, and amended for clarity. These were presented to experts for agreement ranking in round 2, with consensus defined as ≥70% agreement.

RESULTS

Both rounds were completed by 47 international experts. In round 1, 1102 qualitative responses were received. Of the 200 statements presented to experts across 2 rounds, 130 (65%) reached consensus. Results were discussed at 2 international subject-specific conferences in June 2022. Experts agreed on a diagnostic definition for VCD/ILO and endorsed the concept of VCD/ILO phenotypes and clinical descriptions. The panel agreed that laryngoscopy with provocation is the gold standard for diagnosis and that ≥50% laryngeal closure on inspiration or Maat grade ≥2 define abnormal laryngeal closure indicative of VCD/ILO.

CONCLUSIONS

This Delphi study reached consensus on multiple aspects of VCD/ILO diagnosis and can inform clinical practice and facilitate research.

Applying behaviour change theory to speech and language therapy intervention for inducible laryngeal obstruction

BACKGROUND

Speech and language therapists (SLTs) provide interventions for inducible laryngeal obstruction (ILO) despite a current lack of evidence to inform intervention delivery. This study is the first step to develop an evidence-based intervention for ILO, using behaviour change theory and the Behaviour Change Technique Taxonomy version 1 (BCTTv1). Outcomes will inform the early development stage of a complex speech and language therapy intervention for ILO, enabling more precise reporting of ILO intervention studies, as per CONSORT guidelines.

AIMS

(1) To identify whether the BCTTv1 is a useful tool for characterising speech and language therapy interventions for ILO, based on existing literature, current practice and patient interviews. (2) To identify key behaviour change techniques (BCT) used within existing complex speech and language therapy interventions for ILO METHODS AND PROCEDURES: A five-phase study was conducted: (1) a systematic literature search of six electronic databases (Medline, EMBASE, CINAHL (EBSCO), Scopus, Trip, Web of Science) and grey literature between 2008 and 2020; (2) observations of six speech and language therapy intervention sessions; (3) a semi-structured interview with an SLT to validate the observed BCTTs; (4) consensus from four national expert SLTs regarding application of synthesised BCTT data to their own experiences of ILO interventions; and (5) patient engagement to review and comment on findings.

OUTCOMES AND RESULTS

Forty-seven BCTs in total were coded across all three sources. Thirty-two BCTs were identified in clinical observations; 31 in interviews with SLTs and 18 in the literature. Only six BCT were identified in all three sources. Expert SLTs confirmed clinical application and relevance. Patients reported finding the concept of BCT challenging but highlighted the value of psychoeducation to support their understanding of symptoms and in turn to understand the rationale behind speech and language therapy intervention recommendations.

CONCLUSION

This study indicates that the BCTTv1 is a suitable framework to identify and describe intervention components used within speech and language therapy interventions for ILO. A practice-research gap exists, reinforcing that existing literature does not capture the complexity of speech and language therapy intervention for ILO. Further research is needed to develop our understanding of the BCTs that support optimal behaviour change for this patient group.

WHAT THIS PAPER ADDS

What is already known on the subject There is growing recognition for the value of speech and language therapists (SLTs) in delivering complex interventions for patients with inducible laryngeal obstruction (ILO), including evidence to suggest that their intervention can improve quality of life for patients and reduce excessive healthcare use. There are, however, no randomised controlled trials in this field; thus it is unclear what constitutes the most effective intervention. What this study adds This study demonstrates the complexity of speech and language therapy interventions for ILO and highlights the practice-research gap. It identifies a range of behaviour change techniques that are used in existing practice and captures patient views relating to the components identified within this study. What are the clinical implications of this work? Findings highlight the value of providing education about factors that might be driving ILO symptoms and in turn the importance of sharing with patients the rationale for treatment recommendations that necessitate a change in their behaviours. Identified behaviour change techniques can be used when developing and implementing SLT interventions for ILO.

Management of comorbidities in difficult and severe asthma

Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.

Expanded central role of the respiratory physiotherapists in the community setting

The development of community hubs through the Slaintecare initiative will rely on respiratory physiotherapists and clinical nurse specialists for the management of chronic respiratory diseases. The role of the respiratory physiotherapist has evolved dramatically over the last decade. We review the increasing scope of practice of the physiotherapist and the evidence base for same. We pay particular attention to the role of the physiotherapist in areas such as pulmonary rehabilitation, sputum clearance, neuromuscular disease, chronic respiratory failure, ambulatory oxygen assessments and dysfunctional breathing. We give an in depth review of sputum clearance techniques. We also address areas of potential future expansion for the role of the physiotherapist such as prescription and initiation of non-invasive ventilation.

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.

Vocal cord dysfunction/inducible laryngeal obstruction-2022 Melbourne Roundtable Report

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO), is a common condition characterized by breathlessness associated with inappropriate laryngeal narrowing. Important questions remain unresolved, and to improve collaboration and harmonization in the field, we convened an international Roundtable conference on VCD/ILO in Melbourne, Australia. The aims were to delineate a consistent approach to VCD/ILO diagnosis, appraise disease pathogenesis, outline current management and model(s) of care and identify key research questions. This report summarizes discussions, frames key questions and details recommendations. Participants discussed clinical, research and conceptual advances in the context of recent evidence. The condition presents in a heterogenous manner, and diagnosis is often delayed. Definitive diagnosis of VCD/ILO conventionally utilizes laryngoscopy demonstrating inspiratory vocal fold narrowing >50%. Computed tomography of the larynx is a new technology with potential for swift diagnosis that requires validation in clinical pathways. Disease pathogenesis and multimorbidity interactions are complex reflecting a multi-factorial, complex condition, with no single overarching disease mechanism. Currently there is no evidence-based standard of care since randomized trials for treatment are non-existent. Recent multidisciplinary models of care need to be clearly articulated and prospectively investigated. Patient impact and healthcare utilization can be formidable but have largely escaped inquiry and patient perspectives have not been explored. Roundtable participants expressed optimism as collective understanding of this complex condition evolves. The Melbourne VCD/ILO Roundtable 2022 identified clear priorities and future directions for this impactful condition.

Computed Tomography Imaging of the Larynx for Diagnosis of Vocal Cord Dysfunction

BACKGROUND: Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is characterized by breathlessness and often mimics or accompanies severe asthma. The disorder occurs intermittently, and the diagnosis is established by using laryngoscopy. Dynamic computed tomography (CT) imaging of the larynx at low-radiation doses has the potential to provide an alternative method to make the diagnosis of VCD/ILO. METHODS: We report two case series: in series A, laryngoscopy (diagnostic standard) and CT imaging of the larynx were each performed within 1 hour of each other (n=31), and in series B, the procedures were performed on separate days 4 to 6 weeks apart (n=72). Diagnosis of VCD/ILO by laryngoscopy used conventional criteria, and diagnosis by CT imaging was based on vocal cord narrowing in excess of a validated normal threshold. In each series, we evaluated the accuracy of CT imaging of the larynx to establish a diagnosis of VCD/ILO compared with laryngoscopy. RESULTS: In series A, the sensitivity of CT imaging of the larynx was 53.8%, and specificity was 88.9%; in series B, the sensitivity of CT imaging of the larynx was 76.2%, and specificity was 93.3%. At a disease prevalence of 30% (which was known to be the case in our clinic), the positive predictive value was 67.5% in series A and 83% in series B. Negative predictive values were 81.8% and 90.1% in series A and B, respectively, and false-positive rates were 11.1% and 6.7%. CONCLUSIONS: When the population prevalence was assumed to be 30%, low-dose CT imaging of the larynx detected VCD/ILO with negative predictive values greater than 80% in both series settings and agreed with each other within 9 percentage points. Positive predictive values for laryngeal CT imaging varied substantially between the settings of the two case series. (Supported by Monash Lung and Sleep Institute and Grant APP ID 1198362 and others.)

Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics

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.

Factors impacting therapy duration in children and adolescents with Paradoxical Vocal Fold Movement (PVFM)

PURPOSE

Paradoxical Vocal Fold Movement (PVFM) may cause airway restriction and resulting dyspnea in the pediatric population. Therapy with a speech-language pathologist (SLP) is the primary treatment for children and adolescents diagnosed with Paradoxical Vocal Fold Movement (PVFM). This study examined treatment duration and factors predicting number of therapy sessions required.

METHODS

Data were drawn from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. One hundred and twelve children and adolescents were included in this study. Participants were diagnosed with PVFM, followed for therapy with a SLP, and were subsequently discharged from therapy with successful outcomes. Extracted data included number of therapy sessions, PVFM symptoms, patient demographics, medical history, and comorbid diagnoses. Regression was used to determine factors predicting therapy duration.

RESULTS

Patients completed an average of 3.4 therapy sessions before discharge. Comorbid behavioral health diagnosis (β = 1.96, t = 3.83, p < .01) and a history of upper airway surgeries (β = 1.26, t = 2.615, p = .01) were significant predictors of the number of therapy sessions required before discharge; both factors significantly increased therapy duration. Age, symptom trigger-type, reflux symptoms, and dysphonia did not predict therapy duration. Overall, our regression model accounted for 42% of the variance in number of sessions required (r² = 0.42).

CONCLUSIONS

On average, 3.4 sessions of therapy with an SLP resolved PVFM symptoms. Children with a behavioral health diagnosis required an average of 5.45 sessions and those with a history of upper airway surgery an average of 4.3 sessions. Future work should examine the relationship between behavioral health care and PVFM treatment, as well as how PVFM treatment efficiency can be maximized.

A case of vocal cord dysfunction in the emergency department

We describe the case of a 78-year-old woman admitted to our emergency department for an acute onset of severe dyspnoea with inspiratory wheezing-like sounds. She denied fever, cough, voice change and pain. She referred a similar but less severe episode occurred spontaneously one year before, with complete resolution in few minutes without sequelae. On examination upper airway obstruction was firstly excluded. She was initially treated as having asthma, without response. Parenteral high dose corticosteroids and antihistamines provided no benefit. Point-of-care-ultrasound resulted normal. Flexible laryngoscopy during the episode showed paradoxical vocal cord movement with adduction during both inspiration and expiration. This demonstrated that her dyspnoea was from Vocal Cord Dysfunction (VCD). VCD completely solved after administration of intravenous benzodiazepines.

Systematic review of the effectiveness of non-pharmacological interventions used to treat adults with inducible laryngeal obstruction

Introduction

Inducible laryngeal obstruction (ILO) describes transient laryngeal closure during respiration and can cause significant morbidity. Non-pharmacological behavioural therapy is the commonly cited treatment but efficacy is largely unknown.

Aim

To synthesise the current evidence base on the effectiveness of non-pharmacological interventions used to treat adults with ILO.

Methods

Electronic databases (Medline/Embase/CINAHL/PsycINFO/AMED/CENTRAL) were systematically searched, informed by a population, intervention, comparison, outcome framework. Two reviewers independently screened a representative sample, with lead-author completion due to excellent inter-rater reliability. Data was extracted using a predefined piloted form. Methodological quality was appraised (blindly by two reviewers) using the Joanna Briggs Institute Critical Appraisal Tools. A narrative synthesis was performed due to heterogeneity of studies (PROSPERO registration number: CRD42020213187).

Results

Initial searching identified 3359 records. Full-text screening occurred in 92 records and 14 studies, comprising 527 participants, were deemed eligible. All studies were low-level evidence (observational by design, with four case reports), with a high risk of bias; none contained control arms for comparison. Intervention description was inconsistently and poorly described but direction of effect was positive in 76% of outcomes measured. The majority of studies showed a reduction in symptom scores and improved direct laryngeal imaging post intervention; there was an overall reduction, 59.5%, in healthcare utilisation.

Discussion

The literature is in an embryonic state and lacks robust data to truly inform on the effectiveness of non-pharmacological interventions used to treat adults with ILO. However, positive signals in the synthesis performed support non-pharmacological treatment approaches and further development is warranted.