Paradoxical vocal cord motion disorder: past, present and future

A case of paradoxical vocal cord movement misdiagnosed as anaphylaxis

INTRODUCTION

Anaphylaxis is a severe and life-threatening systemic hypersensitivity reaction. The most frequently encountered causes are foods, drugs, and bee venom, but anaphylaxis may also occur idiopathically. Paradoxical vocal cord movement (PVCM), is a cause of upper airway obstruction due to abnormal adduction of vocal cords during inspiration and, to some degree on expiration. It may be misdiagnosed as asthma or anaphylaxis, and there may be delays in diagnosis.

CASE REPORT

We present a 20-year-old male patient with coexistence of urticaria and stridor findings who was evaluated and treated as having idiopathic anaphylaxis but then was diagnosed with PVCM after recurrence of stridor attacks.

CONCLUSION

It is useful to bear the diagnosis of PVCM in mind in patients with recurrent and unexplained stridor or in patients with stridor that does not improve despite treatment for another diagnosis such as anaphylaxis. This way, administration of epinephrine, high-dose corticosteroids and interventions such as intubation or tracheostomy can be avoided.

Allergic Diseases and Mental Health

Neuropsychiatric symptoms have long been acknowledged as a common comorbidity for individuals with allergic diseases. The proposed mechanisms for this relationship vary by disease and patient population and may include neuroinflammation and/or the consequent social implications of disease symptoms and management. We review connections between mental health and allergic rhinitis, atopic dermatitis, asthma, vocal cord dysfunction, urticaria, and food allergy. Many uncertainties remain and warrant further research, particularly with regard to how medications interact with pathophysiologic mechanisms of allergic disease in the neuroimmune axis. Proactive screening for mental health challenges, using tools such as the Patient Health Questionnaire and Generalized Anxiety Disorder screening instruments among others, can aid clinicians in identifying patients who may need further psychiatric evaluation and support. Although convenient, symptom screening tools are limited by variable sensitivity and specificity and therefore require healthcare professionals to remain vigilant for other mental health "red flags." Ultimately, understanding the connection between allergic disease and mental health empowers clinicians to both anticipate and serve the diverse physical and mental health needs of their patient populations.

Logical Fallacies in Missed Diagnosis of Stridorous Patients: A Case Report

Tracheal stenosis and paradoxical vocal fold motion are both common laryngological diagnoses that can present with similar symptoms of dyspnea. Co-morbid psychiatric issues can complicate diagnostic accuracy and lead to logical fallacies in the attribution of symptom etiology. We present a case of a 38-year-old female who presented repeatedly to the emergency department with respiratory distress, inspiratory stridor, wheezing, and anxiety. On examination, she had stridor that appeared to correlate with episodes of elevated anxiety and bedside laryngoscopy which showed intermittent paradoxical vocal fold motion. A computed tomography scan showed 40% narrowing of the distal tracheal lumen, but symptoms were felt to be inconsistent and out of proportion to stenosis. She was seen several more times in the ED and eventually followed up in the laryngology clinic, where she had a tracheoscopy showing Cotton Meyer grade III stenosis. This unique case highlights the logical fallacies that may lead to misdiagnosis when evaluating stridorous patients with comorbid personality and anxiety disorders.

Persistent Shortness of Breath in Post-COVID-19 Patients: Inducible Laryngeal Obstruction Can Be a Cause

BACKGROUND

Inducible laryngeal obstruction (ILO) is the adduction of the true vocal folds during inspiration or, less frequently, expiration. Its etiology is unknown.

PURPOSE

This study aimed to identify ILO as a possible cause of shortness of breath (SOB) in post-COVID-19 patients.

METHODS

A retrospective study was conducted on 59 post-COVID-19 adults complaining of SOB. We collected the cases' clinical and chest imaging data, including demographic data, pulmonary function test (PFT), CT chest, and laryngeal endoscopic examination. A visual score was used to assign the severity of the glottic obstruction. The grades of this score ranged from 0 (complete patency) to 3 (almost complete closure).

RESULTS

ILO was detected in 8 out of 59 cases (13.5%). Two cases out of eight had glottic closure grade 1, while five cases had glottic closure grade 2, and one had glottic closure grade 3. There was a positive correlation between ILO grades (the severity of glottic closure) and PFT results (the degree of upper airway restriction). PFTs in ILO have a specific pattern. It was typical for the expiratory loop to be normal and the inspiratory loop to be flattened.

CONCLUSION

ILO is a possible cause of SOB in post-COVID-19 adult cases. It should be considered during evaluation and management.

Vocal Cord Dysfunction During the COVID-19 Pandemic

BACKGROUND

Vocal cord dysfunction is an upper-airway disorder characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms. Common presentation is with inspiratory stridor often in the context of emotional stress and anxiety. Other symptoms include wheezing (which may be on inspiration), frequent cough, choking sensation, or throat and chest tightness. This is seen commonly in teenagers, particularly in adolescent females. The COVID-19 pandemic has been a trigger for anxiety and stress with an increase in psychosomatic illness. Our objective was to find out if the incidence of vocal cord dysfunction increased during COVID-19 pandemic.

METHODS

We performed a retrospective chart review of all the subjects with a new diagnosis of vocal cord dysfunction who were seen at the out-patient pulmonary practice at our children's hospital between January 2019-December 2020.

RESULTS

The incidence of vocal cord dysfunction in 2019 was found to be 5.2%, (41/786 subjects seen) compared to 10.3% (47/457 subjects seen) in 2020, which is a nearly 100% increase in incidence (P < .001).

CONCLUSIONS

It is important to recognize that vocal cord dysfunction has increased during the COVID-19 pandemic. In particular, physicians treating pediatric patients, as well as respiratory therapists, should be aware of this diagnosis. It is imperative to avoid unnecessary intubations and treatments with bronchodilators and corticosteroids as opposed to behavioral and speech training to learn effective voluntary control over the muscles of inspiration and the vocal cords.

Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial

Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and β-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.

Clinical presentation of paradoxical vocal fold motion or laryngeal dyskinesia in infants

OBJECTIVES

Paradoxical vocal fold motion (PVFM) is not well-characterized in infants. Sex- and race/ethnicity-based differences have been described in older children with PVFM. This study's objectives are to characterize demographic and clinical characteristics of infants diagnosed with PVFM and investigate sex- and race-specific differences in presentation.

METHODS

We retrospectively reviewed infants ≤1 year of age diagnosed with PVFM at our institution from 2009 to 2019. Patient demographics, symptoms, and findings on flexible laryngoscopy are described. Sex- and race/ethnicity-based differences were assessed using Fisher's exact test analyses.

RESULTS

We identified 22 infants who were diagnosed with PVFM. The average age (range) at diagnosis was 5.7 (0.25-12.0) months, and 45.5% were male. The majority (54.6%) of patients identified as non-Hispanic White. Common comorbidities included GERD (45.5%) and chronic rhinitis (13.6%). Stridor was the only presenting symptom in the majority of patients (95.4%). The most common episode triggers were crying (45.5%), feeding (27.3%), and gastric reflux (9.1%). On flexible laryngoscopy, PVFM was observed in 95.5% of patients. A third of patients (31.8%) were misdiagnosed as having reactive airway disease or laryngomalacia prior to evaluation by otolaryngology. No sex- and race/ethnicity-based differences in presentation were identified.

CONCLUSION

We present the largest case series of PVFM in infants. We found sparse clinical signs/symptoms other than stridor and a high incidence of misdiagnosis, which supports the importance of objective flexible laryngoscopy for the evaluation of stridor in this age group. Previously reported sex- and race/ethnicity-based differences in presentation of PVFM were not observed in this cohort of infants.

The impact of identifying laryngeal obstruction syndromes on reducing treatment of pediatric asthma: A systematic review

Inducible laryngeal obstruction (ILO) in children is underrecognized. This systematic review characterizes the scientific evidence on the impact of pediatric ILO diagnosis and treatment on asthma medication use. This review, registered with PROSPERO (CRD42020209168), utilized database searches in MEDLINE, EMBASE, CINAHL, and Web of Science from inception to October 2020. Both experimental and observational studies on ILO and asthma outcomes in patients ≤18 years were included. Population characteristics (sample size, sex, age, and comorbidities) and study outcomes (medication usage and respiratory symptoms) were extracted. The risk of bias was assessed with the National Toxicology Program's Office of Health Assessment and Risk of Bias Rating Tool. Data are presented narratively due to study heterogeneity. Of 1091 studies, 1076 titles and abstracts were screened after duplicate removal. Screening 31 full texts yielded eight pre-post studies. Patients were an average of 14.1 years old, 15% male, and >90% used asthma medication; 40% reported allergies, 30% gastroesophageal reflux, and 20% anxiety or depression. Most patients received at least one intervention, with 75% showing symptomatic improvement and >75% decreasing or stopping asthma medications. Studies were small with a high risk of selection, confounding, and detection bias. Asthma management was not a primary outcome in any of the studies. Overall, ILO patients were often diagnosed with or treated for asthma before ILO diagnosis. Evidence from individual studies suggests that comorbidities including ILO, gastroesophageal reflux, allergies, and anxiety should be considered in pediatric patients with asthma not responsive to medical therapy. Further research is required to determine the proportion of impacted asthma patients.

Post-COVID-19 paradoxical vocal cord movement and dysfunctional dysphonia: A clinical case

Introduction

Post-COVID persistent dyspnea linked to a paradoxical vocal fold movement has rarely been described, and it has never been described as associated with dysfunctional dysphonia.

Case study

We present a case of a 46-year-old patient with severe COVID-19 history who presented to our hospital for persistent cough, dysphonia, and intermittent episodes of dyspnea, getting worse when speaking. A chest computed tomography (CT) scan done was normal. The patient was treated by empiric bronchodilators with inhaled corticosteroids but without any improvement. A bronchoscopy was done and revealed spontaneous paradoxical vocal fold movement and dysfunctional dysphonia. The patient was referred to a speech therapist, and her problem was resolved.

Conclusion

Resistant dyspnea to empiric treatment, after COVID-19, should suggest the diagnosis of paradoxical vocal fold movement. Laryngoscopy should be done to confirm the diagnosis, and the patient should be referred to a speech therapist.

[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.

Reduced Asthma Medication Use after Treatment of Pediatric Paradoxical Vocal Fold Motion Disorder

OBJECTIVES/HYPOTHESES

The primary objective of this study was to determine whether the diagnosis and treatment of pediatric Paradoxical Vocal Fold Motion Disorder (PVFMD) leads to decreased asthma medication use. Our secondary objective was to determine dyspnea outcomes following diagnosis and treatment for PVFMD.

STUDY DESIGN

Prospective observational study.

METHODS

Patients with newly diagnosed PVFMD between the ages of 11 and 17 were recruited at a single pediatric institution. A medication questionnaire and Dyspnea Index (DI) were completed at the initial visit, at the first return visit, and at greater than 6 months post-diagnosis and therapy. Laryngeal Control Therapy (LCT) consisted of teaching breathing techniques and identifying emotional, physical, and environmental contributing factors and strategies to reduce them.

RESULTS

Twenty-six patients were recruited to the study. There were 19/26 (73%) patients diagnosed with asthma prior to a diagnosis of PVFMD, and 26/26 (100%) patients were using an inhaler prior to the enrollment visit. Twenty-two (85%) patients completed follow-up questionnaires. Five patients participated in no therapy, seven patients in partial therapy, and 14 patients in full therapy. Significant reduction in asthma medication use was seen in the full therapy group (P < .05) and in those with exercise as their only trigger (P < .05). Furthermore, symptoms as scored by the DI decreased overall from 25.5 to 18.8 (P < .001).

CONCLUSIONS

Diagnosis and treatment of pediatric PVFMD leads to a decline in asthma medication use in those patients who participate in at least two LCT sessions and in those with exercise-induced PVFMD. LCT for pediatric PVFMD leads to a significant decrease in symptoms as measured by the DI.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1639-1646, 2021.

Obstructive Sleep Apnea with Paradoxical Vocal Cord Movement in Children during Sleep Endoscopy: Case Series

Objective

To describe a series of pediatric cases of obstructive sleep apnea (OSA) with paradoxical vocal cord movement noted on drug-induced sleep endoscopy (DISE).

Materials and Methods

Case series and chart review of children who had undergone DISE for OSA that showed PVCM.

Results

Three cases where paradoxical vocal cord motion (PVCM) was noted during DISE are described. Two had an enlarged adenoid, and one had no other site of obstruction. Two were treated with adenoidectomy and antireflux medications. One received proton pump inhibitors alone. In all 3 cases, OSA symptoms resolved.

Conclusion

This case series of documented obstructive sleep apnea related to paradoxical vocal cord movement suggests that this entity occurs during sleep with airway obstruction. Further clarification of etiology of PVCM during OSA and its management is needed.

Paradoxical Vocal Fold Movement: A Retrospective Analysis

BACKGROUND

Paradoxical vocal fold motion (PVFM) is a disorder in which the vocal folds adduct inappropriately during inspiration resulting in episodic dyspnea and sometimes respiratory distress. Diagnosis is obtained through careful history, physical examination, flexible laryngoscopic examination with provocative maneuvers, and laryngeal electromyography. The pathogenesis and clinical findings of this disorder are not known.

OBJECTIVES

To determine characteristics of patients with confirmed PVFM and to evaluate efficacy of current treatments.

METHODS

A retrospective chart review of the patients with PVFM who presented at a quaternary care laryngology office between January 1, 2007 and August 31, 2019 was performed. Comorbidities, laboratories tests, imaging, 24-hours pH impedance testing, and laryngeal EMG results were analyzed. Dyspnea Index questionnaire before and after treatment was used to evaluate the efficiency of treatments for PVFM.

RESULTS

The average age of the 40 patients was 30.25 years. Forty-five percent of patients were under the age of 18, and 80% were female. Twenty-five percent of patients were serious athletes, and 40% of patients were students. Sixty-five percent had a previous diagnosis of asthma. One third of patients had concurrent psychiatric diagnosis. There was no family history of PVFM in the cohort. There were no other common findings. Treatment for laryngopharyngeal reflux (LPR) was used only when there was evidence of LPR; and 93% of our 40 patients received LPR treatment. Ninety percent of patients who received botulinum toxin, voice therapy (VT), and LPR treatment had subjective improvement. Patients with just VT and LPR treatment had a 43% subjective improvement rate; and the difference was statistically significant at P of 0.021. There was no statistical difference between VT and LPR treatment versus VT or LPR treatment alone.

CONCLUSION

Botulinum toxin, VT, and LPR treatment regimen is currently the most effective management for patients with paradoxical vocal fold movement disorder. More research is needed to determine the etiology of this disorder.

A unique presentation and etiology of neonatal paradoxical vocal fold motion

We present a unique case of intermittent paradoxical vocal fold motion (PVFM) as the presenting symptom of a rare underlying neuromuscular disorder in a neonate. Paramyotonia congenita (PC) is an autosomal dominant condition that typically presents in infancy with myotonic episodes affecting the skeletal muscles. Our patient developed intermittent episodes of stridor quickly progressing to apnea shortly after birth that were marked by PVFM on laryngoscopy, ultimately leading to the diagnosis of a previously unrecognized mutation in SCN4A, the gene responsible for PC.

Paroxysmal laryngospasm: Episodic closure of the upper airway

Paroxysmal laryngospasm is an episodic event, resulting in complete closure of the larynx caused by hypersensitization of laryngeal tissue and protective laryngeal reflexes. This condition most often occurs secondary to laryngopharyngeal reflux. Prognosis generally is good after treatment is initiated; however, often because of a misunderstanding of the clinical course and potential causes, patients with paroxysmal laryngospasm can go untreated. This article describes paroxysmal laryngospasm, similarly presenting diseases, and treatment strategies.

Heliox for inducible laryngeal obstruction (vocal cord dysfunction): A systematic literature review

OBJECTIVES

To perform a systematic literature review on the use of Heliox with patients with inducible laryngeal obstruction/vocal cord dysfunction to: i) identify current evidence base; and ii) establish the methodological quality of published research.

METHODS

Articles published up to March 2018 were searched for key words and terms using Cochrane Library, MEDLINE, PubMed, CINAHL, EMBASE and Dynamed. Studies were included if they presented original research into the use of Heliox for vocal cord dysfunction.

RESULTS

Only three studies met the inclusion criteria for review. All reported favorable results for the use of Heliox as an adjunctive therapy for vocal cord dysfunction but none had sufficient methodological quality to support their conclusions.

CONCLUSION

Despite review articles recommending the use of Heliox in vocal cord dysfunction, there is a lack of good quality research to support this conclusion. There is a need for further research to investigate the effectiveness of Heliox as an adjunctive therapy for vocal cord dysfunction.

LEVEL OF EVIDENCE

4.

Spirometry and provocation tests for vocal fold dysfunction diagnosis: a retrospective case series

AIMS Vocal cord dysfunction (VCD) is characterised by paradoxical inspiratory laryngeal motion and is often misdiagnosed as asthma. Definitive diagnosis of VCD is difficult, because laryngoscopy is positive only during symptomatic episodes or upon provocation with exercise or inhaled irritants. The aims of the study were to better characterise the symptomatology of patients with VCD and to evaluate the potential usefulness of less-invasive diagnostic tools, namely provocation tests and spirometry. METHODS Retrospective case series of 84 patients with a typical clinical history of VCD, in whom at least one of the three following diagnostic tests were performed: laryngoscopy, provocation testing, or spirometry. RESULTS The mean age of the patients was 51 years and 74% were women. The principal comorbidities were rhinosinusitis (60%), gastro-oesophageal reflux disease (56%) and atopy (54%). Diagnosis of VCD was confirmed in 73/84 cases (87%), by laryngoscopy (8%), spirometry (84%) and/or provocation tests (68%). CONCLUSIONS VCD remains an underdiagnosed condition. A negative finding on laryngoscopy can lead to false negative diagnosis if it is done when the patient is asymptomatic. Here we show that a clinical suspicion of VCD, evoked by medical history, can be confirmed in many cases by less invasive diagnostic tools such as spirometry and provocation tests. Future well-conducted prospective case-control studies are needed to draw firmer conclusions and to improve the diagnostic accuracy of this condition.

Gasping for a Diagnosis: Pediatric Vocal Cord Dysfunction

Vocal cord dysfunction is an obstruction of the upper airway, primarily on inspiration, due to the paradoxical adduction of the vocal cords. Vocal cord dysfunction continues to be underdiagnosed as its own entity. The lack of diagnosis can be attributed to the overlap of symptoms between asthma and exercise-induced bronchospasm. It is possible for patients diagnosed with asthma and/or exercise-induced bronchospasm to have underlying vocal cord dysfunction, which needs to be considered when prescribing asthma medications. This article will review the history of vocal cord dysfunction, the differential diagnosis, diagnostic testing, and the role of the nurse practitioner in caring for these patients.

Dysfunctional Breathing in Children and Adults With Asthma

Asthma occurs across the life course. Its optimal treatment includes the use of personalized management plans that recognize the importance of co-morbidities including so-called "dysfunctional breathing." Such symptoms can arise as a result of induced laryngeal obstruction (ILO) or alterations in the mechanics of normal breathing called breathing pattern disorders. Whilst these two types of breathing abnormalities might be related, studies tend to focus on only one of them and do not consider their relationship. Evidence for these problems amongst childhood asthmatics is largely anecdotal. They seem rare in early childhood. Both types are more frequently recognized in the second decade of life and girls are affected more often. These observations tantalizingly parallel epidemiological studies characterizing the increasing prevalence and severity of asthma that also occurs amongst females after puberty. Exercise ILO is more common amongst adolescents and young adults. It should be properly delineated as it might be causally related to specific treatable factors. More severe ILO occurring at rest and breathing pattern disorders are more likely to be occurring within a psychological paradigm. Dysfunctional breathing is associated with asthma morbidity through a number of potential mechanisms. These include anxiety induced breathing pattern disorders and the enhanced perception of subsequent symptoms, cooling and drying of the airways from hyperventilation induced hyperresponsiveness and a direct effect of emotional stimuli on airways constriction via cholinergic pathways. Hyperventilation is the most common breathing pattern disorder amongst adults. Although not validated for use in asthma, the Nijmegen questionnaire has been used to characterize this problem. Studies show higher scores amongst women, those with poorly controlled asthma and those with psychiatric problems. Evidence that treatment with breathing retraining techniques is effective in a primary care population including all types of asthmatics suggests the problem might be more ubiquitous than just these high-risk groups. Future challenges include the need for studies characterizing all types of dysfunctional breathing in pediatric and adult patient cohorts and clearly defined, age appropriate, interventional studies. Clinicians caring for asthmatics in all age groups need to be aware of these co-morbidities and routinely ask about symptoms that suggest these problems.

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.

Psychogenic non-epileptic seizures in children and adolescents: Part I - Diagnostic formulations

Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations - the clinical formulations about the probable neurophysiological mechanisms - that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet's dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES.

The Vocal Fold Dysfunction Questionnaire: Validity and Reliability of the Persian Version

OBJECTIVES

The aim of this study was to develop, validate, and assess the reliability of the Persian version of Vocal Cord Dysfunction Questionnaire (VCDQ_P).

STUDY DESIGN

The study design was cross-sectional or cultural survey.

MATERIALS AND METHODS

Forty-four patients with vocal fold dysfunction (VFD) and 40 healthy volunteers were recruited for the study. To assess the content validity, the prefinal questions were given to 15 experts to comment on its essential. Ten patients with VFD rated the importance of VCDQ_P in detecting face validity. Eighteen of the patients with VFD completed the VCDQ 1 week later for test-retest reliability. To detect absolute reliability, standard error of measurement and smallest detected change were calculated. Concurrent validity was assessed by completing the Persian Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) by 34 patients with VFD. Discriminant validity was measured from 34 participants. The VCDQ was further validated by administering the questionnaire to 40 healthy volunteers. Validation of the VCDQ as a treatment outcome tool was conducted in 18 patients with VFD using pre- and posttreatment scores.

RESULTS

The internal consistency was confirmed (Cronbach α = 0.78). The test-retest reliability was excellent (intraclass correlation coefficient = 0.97). The standard error of measurement and smallest detected change values were acceptable (0.39 and 1.08, respectively). There was a significant correlation between the VCDQ_P and the CAT total scores (P < 0.05). Discriminative validity was significantly different. The VCDQ scores in patients with VFD before and after treatment was significantly different (P < 0.001).

CONCLUSIONS

The VCDQ was cross-culturally adapted to Persian and demonstrated to be a valid and reliable self-administered questionnaire in Persian-speaking population.

Benign Rolandic epilepsy presenting like paradoxical vocal fold motion

Paradoxical vocal fold motion (PVFM) is characterized by vocal fold adduction during respiration. Benign Rolandic epilepsy (BRE) is the most common childhood epilepsy and can cause oropharyngolaryngeal or facial manifestations. A 9-year-old male presented with intermittent apnea lasting 30-60 seconds and presumed PVFM. The patient's physical and fiberoptic exam were normal. He was admitted and found to have episodes of oxygen desaturation, neck twitching, and tongue burning. An EEG revealed focal epilepsy. After starting anti-epileptic medications, he had resolution of symptoms. Our patient was eventually diagnosed with BRE, a focal onset epilepsy that can mimic primary otolaryngologic disease.

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.

Fragrances and work-related asthma-California surveillance data, 1993-2012

OBJECTIVE

Fragrance chemicals are used in a large array of products. Workers may be exposed to these chemicals in the workplace directly when used as air fresheners, or indirectly in personal care products used by coworkers or others. This study characterizes work-related asthma (WRA) cases associated with fragrance exposures in California workplaces from 1993 through 2012.

METHODS

We used the California Work-Related Asthma Prevention Program's surveillance database to identify individuals with physician-diagnosed WRA associated with the use of air fresheners and scented personal care products (perfumes, colognes, etc.). Cases were classified using previously published, standardized surveillance methods.

RESULTS

Perfume was the ninth most common exposure identified from 1993 through 2012. A total of 270 WRA cases associated with fragrance exposure were reported during this period, representing 3.8% of all confirmed cases. These 270 cases included 242 associated with perfume or cologne, 32 associated with air freshener, and 4 associated with both. Similar to non-fragrance cases, nearly a quarter of fragrance-associated cases were classified as new-onset asthma. Fragrance-associated cases were significantly more likely to be in office, health, and education jobs than non-fragrance-associated cases. When compared to non-fragrance cases, fragrance cases were significantly more likely to be female (94% vs 62%) and be classified as having work-aggravated asthma (38% vs 20%), yet had similar outcomes compared with cases associated with other exposures.

CONCLUSIONS

Our surveillance data show that fragrance use in the workplace is associated with WRA. Prevention methods include employee education, enforced fragrance-free policies, well-designed ventilation systems, and good building maintenance.

One Hundred Case Series of Vocal Cord Dysfunction in a Military Treatment Facility

The authors' evaluation of vocal cord dysfunction cases reveals that prevalence may be higher than previously reported in the literature.

Measuring Quality of Life in Pediatric Paradoxical Vocal Fold Motion Using the SF-36v2

OBJECTIVES

Paradoxical vocal fold motion (PVFM) consists of intermittent adduction of the vocal folds during inspiration, resulting in stridor and worsened by anxiety and stress. The purpose of this study was to assess the impact of PVFM on quality of life in our pediatric patient population.

STUDY DESIGN

This is a prospective, descriptive survey study.

METHODS

Thirty-nine consecutive patients (ages 12-17 years) presenting with a PVFM diagnosis for respiratory retraining sessions with speech-language pathology were recruited. Patients completed a brief demographic questionnaire and the Short Form 36, version 2, a validated tool for measuring health-related quality of life.

RESULTS

There were 31 (79%) girls and 8 (21%) boys with a mean age of 15.5 years. Subjects reported regular participation in competitive extracurricular activities, including track or cross country (30.8%), swimming (17.9%), and cheerleading or dancing (15.4%). Of the patients in the study, 46.2% were straight-A students. On the SF-36 (population averages normalized to a score of 50), the general health of patients with PVFM was better than that of the general population (53.27); however, their physical health limited their role activities more severely (42.82). In addition, a greater proportion of the group with PVFM was at risk for first-stage depression screening when compared with the general population (28% versus 18%).

CONCLUSIONS

We demonstrate a measurable detrimental impact of PVFM on health-related quality of life. This is consistent with previously published literature showing a preponderance of females with PVFM, most of whom are high achievers academically and athletically.

The forgotten cause of stridor in the emergency department

Paradoxical Vocal Fold Movement Disorder is where the larynx exhibits paradoxical vocal cords closure during respiration, creating partial airway obstruction. Causes of vocal fold movement disorder are multifactorial, and patients describe tightness of throat, difficulty getting air in, have stridor, and do not respond to inhalers. We propose using transnasal laryngoscopy examination, which will show narrowing of vocal cords on inspiration, and The Pittsburgh Vocal Cord Dysfunction Index with a cutoff score of ≥4 to distinguish vocal fold movement disorder from asthma and other causes of stridor. Management of paradoxical vocal fold movement disorder involves a combination of pharmacological, psychological, psychiatric, and speech training. Paradoxical vocal fold movement disorder is a very treatable cause of stridor, so long as it is identified and other organic causes are excluded.

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.

Abnormal vocal cord movement in patients with and without airway obstruction and asthma symptoms

BACKGROUND

Abnormal vocal cord movements can cause laryngeal extrathoracic airway obstruction (often called vocal cord dysfunction - VCD) leading to asthma-like symptoms. These aberrant movements are characteristically present during inspiration and termed paradoxical vocal cord movement (PVCM). We have reported PVCM in up to 40% of severe asthmatics, but it is not known if PVCM is detectable in all patients with asthma-like symptoms and if the condition is more often associated with abnormal lung function.

OBJECTIVE

We hypothesized that PVCM is frequently associated with asthma symptoms accompanied by airflow limitation. Studies examined whether PVCM is solely linked to experiencing asthma symptoms, or if PVCM is related to airflow limitation and/or other disease characteristics.

METHODS

Patients with asthma symptoms were recruited from general practice and severe asthma clinics (n = 155). Pulmonary function measurements were conducted, asthma control and Nijmegen (dysfunctional breathing) questionnaires were administered and skin prick testing was carried out. PVCM was quantified using dynamic 320-slice computerized tomography of the larynx. Groups were divided into patients with FEV₁ ≥ 80% predicted or FEV₁ < 80% predicted and FEV₁ /FVC < 0.7. ATS/ERS definitions of severity were also applied and evaluated. Detection of PVCM in the groups was compared and analyses performed to identify features associated with PVCM.

RESULTS

Overall (n = 155), PVCM was detected in 42 cases (27.1%). Patients with FEV₁ < 80% predicted had PVCM more often (25/68, 36.8%) than individuals with normal spirometry (17/87, 19.5%; P = 0.016). PVCM was associated with older age (P = 0.003) and with Nijmegen scores > 20 (P = 0.04). Patients with FEV₁ < 80% predicted plus Nijmegen scores > 20 were more likely to have PVCM (OR = 9.3, P = 0.02).

CONCLUSIONS AND CLINICAL RELEVANCE

Paradoxical vocal cord movement is more often associated with asthma symptoms accompanied by airflow limitation and dysfunctional breathing. Further studies are needed to determine whether PVCM is induced by dysfunctional breathing practices and/or airway obstruction. How PVCM links with symptomatic asthma and VCD also requires evaluation.

Botulinum toxin injection in laryngeal dyspnea

Data, regarding the use of botulinum toxin (BT-A) in laryngeal dyspnea, are scarce, coming from some cases reports in the literature, including Vocal fold paralysis, laryngeal dystonia, vocal cord dysfunction also called paradoxical motion of the vocal fold (PMVF), and post-neuroleptic laryngeal dyskinesia. There is no consensus regarding the muscles and the doses to inject. The aim of this study is to present a retrospective review of patients treated in our ENT Department by BT-A injection in this indication. This study is a retrospective study describing patients who underwent an injection of botulinum toxin for laryngeal dyspnea in the ENT Department from 2005 to 2015 years. The inclusion criteria were a dyspnea associated with a laryngeal dysfunction, confirmed by flexible fiberoptic nasopharyngolaryngoscopy. Information concerning the causes of the dyspnea, the botulinum toxin BT-A injections procedure, post-injection follow-up, and respiratory outcome were collected for all patients included. In the group of 13 patients included, the main cause identified as principal factor linked with the short breath was: a bilateral VF paralysis (Patel et al., Otolaryngol Head Neck Surg 130:686-689, 7), laryngeal dystonia (Balkissoon and Kenn, Semin Respir Crit Care Med 33:595-605, 2), Anxiety syndrome associated with unilateral vocal fold paralysis or asthma (Marcinow et al., Laryngoscope 124:1425-1430, 3), and an isolated asthma (Zwirner et al., Eur Arch Otorhinolaryngol 254:242-245, 1). Nine out of the thirteen patients were improved by the injections. A BT-A-induced stable benefit for four patients led them to stop the injections in the follow-up. Good outcome was observed in five other patients (main cause: bilateral VP paralysis), allowing a progressive lengthening of the delay between BT-A injections. Four patients did not report a positive risk/benefit ratio after BT-A injections; two of them (with bilateral VF paralysis), because of respiratory side effects and lack of benefit without the side effects for the two others. This failure of effect was not related with BT-A doses injected. This study provides support for using BT-A injections as a symptomatic treatment of periodic laryngeal dyspnea, regardless of the etiologic context. From our data, we suggest that a small starting dose (of around 4 U BT-A Botox^®) could be enough for a first injection to obtain a good benefit. The target muscle should be determined by the EMG analysis.

Clinical associations in the diagnosis of vocal cord dysfunction

BACKGROUND

Diagnosis of VCD is complicated by its symptom similarities to asthma. Although clinical history, spirometry, and fiberoptic nasolaryngoscopy are used for VCD diagnosis, videostroboscopy is considered the gold standard. However, little is know about patient characteristics that might suggest a VCD diagnosis is more likely.

OBJECTIVE

To identify clinical characteristics of patients suspected of having VCD that would increase the likelihood of an accurate diagnosis before videostroboscopy.

METHODS

Records of 55 patients were reviewed for a cross-sectional, retrospective study. Individuals selected were suspected of having VCD because of poor clinical response to asthma medications, absence of objective criteria for diagnosis of asthma (eg, normal forced expiratory volume in 1 second without reversibility, normal exhaled nitric oxide, equivocal methacholine challenge test), or both. We used χ² analyses to determine significant univariate associations of various patient characteristics. Multivariate regression analysis was then performed using those variables identified as being significant predictors by univariate analysis.

RESULTS

A significant association between VCD and age and between VCD and shortness of breath (SOB) was found. Further analysis revealed that at ages younger than 35 years, with every 5-year decrement in age, patients suspected of having VCD in which SOB is the presenting symptom are more likely to have a positive VCD diagnosis by a factor of 1.3.

CONCLUSION

Clinical presentation of younger patients with SOB in conjunction with lack of objective criteria for an asthma diagnosis, poor response to asthma medications, or both is highly predictive of VCD and should prompt an objective stroboscopic evaluation to confirm the diagnosis.

Can PFTS Differentiate PVFMD From Subglottic Stenosis?

OBJECTIVE

To determine if the results of routine spirometry and flow volume loops (Pulmonary Function Tests (PFTs)) can be used to distinguish Paradoxic Vocal Fold Movement Disorder (PVFMD) from Subglottic Stenosis (SGS).

METHODS

PFT records and medical history of 49 patients with diagnosis of PVFMD and 39 patients with SGS were compared. Groups were then subdivided to compare PFTs in patients with and without smoking history or lung disease.

RESULTS

Peak expiratory flow rate (PEFR) and Expiratory Disproportion Index (ratio of forced expiratory volume in 1 second (FEV1) over PEFR (FEV1/PEFR)) were both significantly different between patients with SGS and those with PVFMD (p<0.02). FEV1 was also significantly different, but only in the patients with no smoking history or lung disease (p<0.02).

CONCLUSIONS

The findings suggest that spirometry can be a valuable tool in distinguishing SGS from PVFMD. Previous studies have shown the utility of PFTs for distinguishing SGS from pulmonary pathology, but this is the first study to exploit PFTs for distinction of SGS from PVFMD. Given that the flexible laryngoscopic exam used to diagnose PVFMD does not always visualize the subglottis completely, PFTs can be used to increase suspicion of SGS and direct further work-up.

Paradoxical Vocal Cord Motion in Pediatric Patients

Paradoxical vocal cord motion (PVCM), also termed vocal cord dysfunction, is a poorly understood disorder of episodic dyspnea characterized by inappropriate vocal cord adduction during inspiration and potentially during expiration. It can coexist or be confused with asthma, so appropriate diagnosis is key to optimizing treatment success. Although many patients with PVCM may have underlying psychologic issues, there is emerging evidence to suggest that this entity is not psychogenic in every patient. Both laryngeal irritants and exercise have been identified as additional contributing factors in PVCM. Diagnosis of PVCM requires awake laryngoscopic confirmation. However, many patients do not exhibit signs of PVCM during this examination, despite provocation during testing. Therefore, clinical history remains key in determining which patients should proceed with behavioral therapy under the guidance of a speech pathologist. In addition, treatment may include limiting patient exposure to potential sources of laryngeal irritation. Refractory patients may benefit from psychologic assessment and treatment. [Pediatr Ann. 2016;45(5):e184-e188.].

Diagnosis and investigation in the severe asthma clinic

Severe asthma is recognised as an important and emerging area of unmet need in asthma. The assessment of severe asthma should include three steps; (1) determining the diagnosis of asthma, including verification that the disease is severe asthma, (2) assessing comorbidities and contributing factors that will impact on clinical severity, as well as (3) assessing asthma phenotypes. These steps recognize the importance of heterogeneity in asthma as a key factor that determines the disease course and increasingly the choice of successful therapy. This assessment should be undertaken systematically and is best done by an expert multidisciplinary team. Here, we will outline the important aspects that should be included in the clinical assessment of the patient in the severe asthma clinic, including diagnosis, clinical history, the assessment of important comorbidities and the key investigations needed to support them.

Effectiveness of applying continuous positive airway pressure in a patient with paradoxical vocal fold movement after endotracheal extubation: a case report

Paradoxical vocal fold movement (PVFM) is an uncommon upper airway disorder defined as paradoxical adduction of the vocal folds during inspiration. The etiology and treatment of PVFM are unclear. The physician should manage this condition because of the possibility of near complete airway obstruction in severe case of PVFM. We report a case of successful airway management in a patient with PVFM by applying continuous positive airway pressure (CPAP). In this case, PVFM was detected after removing an endotracheal tube from a 67-year-old male who underwent excision of a laryngeal mass. The patient recovered without complications in 1 day with support by CPAP.

Eucapnic voluntary hyperpnoea and exercise-induced vocal cord dysfunction

INTRODUCTION

Exercise-induced bronchoconstriction (EIB) is a common condition in endurance athletes. Exercise-induced vocal cord dysfunction (EIVCD) is a frequent confounder of EIB. The diagnosis of EIVCD may be challenging and can be missed as the problem is often intermittent and may only occur during intense exercise. Eucapnic voluntary hyperventilation (EVH) is the best test to detect EIB. This pilot study aimed to assess if EVH could be helpful in the diagnosis of EIVCD associated or not to EIB in athletes.

METHODS

A nasolaryngoscopy was performed during a 6 min EVH test, in 13 female athletes suspected to have VCD, aged 21±7 years. Image analysis was conducted by two Ear Nose and Throat surgeons in random order.

RESULTS

During the EVH, three athletes showed incomplete paradoxical vocal cords movement, without inspiratory stridor. However, 12 athletes showed marked supraglottic movement without inspiratory stridor. In two athletes, this supraglottic movement was severe, one showing a marked collapse of the epiglottis with an almost complete obstruction of the larynx by the arytenoid cartilage mucosa. In 3 of the 12 athletes with supraglottic movement, severe vibration of the mucosa covering the arytenoid cartilages was also observed.

CONCLUSIONS

EVH challenge in athletes can provide information on various types of glottic and supraglottic obstruction in reproducing laryngeal movements during hyperventilation. Our findings make us suggest that exercise induced upper airway obstructions should be named: Exercise-induced laryngeal obstruction (EILO). Then, EILO should be divided in three categories: supraglottic, glottic (EIVCD) and mixed (glottic and supraglottic) obstruction.

Paradoxical vocal cord movement during sleep - A unique case with review of literature

Paradoxical vocal cord movement (PVCM) refers to paradoxical adduction of the true vocal cords during inspiration resulting in variable upper airway obstruction. The condition often presents with shortness of breath, wheeze or stridor, mimicking bronchial asthma. Both organic and non-organic causes have been described. PVCM occurring only during sleep has rarely been reported in patients with CNS disease. We present a case of PVCM occurring only during sleep in a 14-year-old boy without any CNS disease, who was initially misdiagnosed as bronchial asthma.

Comparative analysis of clinical profile: Chronic cough vs paradoxical vocal fold motion

BACKGROUND

Ongoing contention surrounding typical demographic and clinical attributes of chronic cough (CC) and paradoxical vocal fold motion (PVFM) impedes timely diagnosis and optimum patient care. Designed to reduce preventable patient morbidity through improved recognition and differentiation, the current study aimed to determine representative clinical profiles for CC and PVFM, with identification of distinctive attributes from the general population and risk factors associated with each diagnosis.

METHODS

Self-reported medical questionnaires, demographic and lifestyle attributes of CC and PVFM cases from a disease-specific outcomes database were compared to US population data and published normative values. Univariate comparison and multivariate regression modelling of age, sex, alcohol intake, smoking, Reflux Symptom Index (RSI), Voice Handicap Index (VHI), and Generalized Anxiety Disorder 7-item Scale (GAD-7) determined distinguishing features between the clinical groups, including odds ratios for presenting with CC versus PVFM.

RESULTS

Clinical profiles developed from 283 (128 CC, 155 PVFM) adults (18-91 years) were significantly different from the general population across each demographic, lifestyle and clinical variable (all p < .01), with the exception of obesity. Age (55.39 ± 13.54 vs 45.07 ± 16.51 years, p < .01) and mean RSI score (21.5 ± 9.02 vs 18.1 ± 9.08, p < .01) most reliably distinguished CC from PVFM, with those aged 60-69 years (OR = 9.45) most likely to be diagnosed with CC.

CONCLUSIONS

Standard clinical profiles of CC and PVFM are distinct from the general population, aiding determination of relative probabilities and risk factors in the differential diagnostic process. Variations between CC and PVFM were subtle, reliably distinguished by age and relative severity of laryngopharyngeal reflux symptomatology.

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.

Differential diagnosis in paradoxical vocal fold movement (PVFM): an interdisciplinary task

OBJECTIVES

The objective of this study was to contribute to the discussion of differential diagnosis in paradoxical vocal fold movement (PVFM), a disorder frequently associated with episodes of breathing difficulty and stridor. Because of analogous respiratory symptoms, PVFM is often misdiagnosed as asthma. Additional evidence suggests the association of factors such as respiratory struggle during physical exertion, digestive reflux, and respiratory allergies with PVFM, particularly in athletes and young females. Interdisciplinary attention is warranted to avoid unnecessary utilization of medical resources and potential delay in the application of proper treatment.

METHODS

A description of critical points in PVFM differential diagnosis is proposed, featuring the assessment of a seven-year-old female with a history of behaviors considered to exacerbate voice fatigue symptoms. Noticeably, the child has consistently demonstrated tiredness and respiratory difficulties during physical education classes. Past use of oral steroids to reduce respiratory problems was applied with no improvement; short-acting beta 2-agonists have been also tried with mild improvement. Indications of instability and effort associated with respiratory-phonatory functions were demonstrated. Furthermore, there was evidence of GERD and seasonal allergies.

RESULTS

The literature suggests an association of factors such as respiratory struggle during physical exertion, unwanted vocal effort, GERD, and respiratory allergies in individuals with PVFM, particularly in young females. A diagnosis of PVFM was suggested, in association with paradoxical vocal folds motion caused by respiratory difficulties verified by laryngeal examination.

CONCLUSIONS

In PVFM, the vocal folds adduct during inhalation, thereby restricting the airway opening. Inconsistent vocal folds movement during phonation may also lead to PVFM symptoms. Acute bronchospasm/asthma-like symptoms, as well as additional morbidity may impact accuracy of diagnosis, leading to unnecessary use of asthma medications and office/emergency room consultations.

Vocal cord dysfunction in bronchial asthma. A review article

INTRODUCTION

Vocal cord dysfunction (VCD) is a condition in which the larynx exhibits paradoxical vocal cord adduction during inspiration, resulting in extra-thoracic variable airway obstruction. It has been described as a mimic of asthma, and hence, many patients with VCD are diagnosed as difficult-to-treat asthma and suffer significant morbidity as such.

METHODS

In completing this review we searched the literature using the database from MEDLINE, PubMed, and the Cochrane library using the medical terms "vocal cord/vocal cord dysfunction and asthma".

RESULTS

During the last few decades, many publications have described many conditions that may cause or coexist with VCD. In addition, the association between asthma and VCD was recognized. In this narrative review we provide an overview of the current knowledge about VCD and, in particular its relationship to asthma. We also provide a pragmatic diagnostic algorithm and treatment options based on our collaborative multi-disciplinary management of patients attending a difficult to control asthma clinic.

CONCLUSION

Most VCD patients present with inadequately controlled asthma rather than the typical symptoms described in association with VCD. Careful diagnostic strategy as outlined in this review may be helpful in confirming the diagnosis.

[Exercise-induced vocal cord dysfunction in asthma: a new diagnostic method]

OBJECTIVE

Vocal cord dysfunction (VCD) is an under-recognized cause of dyspnea and is difficult to diagnose. The symptoms caused by exercise-induced VCD (IEVCD) often falsely suggest asthma, but there is sometimes a real association between the two diseases. The objective of this study was to evaluate a new, simple method for analyzing vocal cord behavior in the diagnosis of IEVCD, and to clarify the prevalence of IEVCD in an uncontrolled asthma population with unexplained exertional dyspnea.

METHODS

This single-center study was conducted prospectively between April 2012 and March 2013. The main inclusion criterion was uncontrolled asthma with unexplained dyspnea. The assessment included cardiopulmonary exercise testing and supraglottal laryngoscopy during exercise with measurement of the vocal cord-opening angle (VCOA). Data from 15 asthmatic patients were compared with those from 10 non-asthmatic dyspneic patients (controls) to define specific criteria for the endoscopic diagnosis of IEVCD.

RESULTS

Endoscopy during bicycle exercising was well tolerated. Normal value of inspiratory VCOA (itVCOA) was>49°. Values for the itVCOA were lower for asthmatics than for controls when exercising at 50% maximal power (52.8°±13.3° and 64.5°±8.3°, respectively). Four of the 15 asthmatics (26%) demonstrated IEVCD characterized with itVCOApeak of less than 49°.

CONCLUSION

Measurement of VCOA represents a new, simple method for obtaining objective data in the exploration of VCD. The prevalence of IEVCD in uncontrolled asthmatic patients is important (26% in our small sample). IEVCD is probably an under-diagnosed aggravating factor in asthma, and its diagnosis and management could avoid the therapeutic climbing in asthma. This method of analysis may help to accurately and objectively assess vocal cord dysfunction.