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Shembel AC, Hartnick CJ, Bunting G, Ballif C, Vanswearingen J, Shaiman S, Johnson A, de Guzman V, Verdolini Abbott K. The Study of Laryngoscopic and Autonomic Patterns in Exercise-Induced Laryngeal Obstruction. Ann Otol Rhinol Laryngol 2018; 127:754-762. [PMID: 30187760 DOI: 10.1177/0003489418796524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES (1) Identify laryngeal patterns axiomatic to exercise-induced laryngeal obstruction (EILO) and (2) investigate the role of autonomic function in EILO. METHODS Twenty-seven athletic adolescents (13 EILO, 14 control) underwent laryngoscopy at rest and exercise. Glottal configurations, supraglottic dynamics, systolic blood pressure responses, and heart rate recovery were compared between conditions and groups. RESULTS Inspiratory glottal angles were smaller in the EILO group than the control group with exercise. However, group differences were not statistically significant ( P > .05), likely due to high variability of laryngeal responses in the EILO group. Expiratory glottal patterns showed statistically greater abductory responses to exercise in the control group ( P = .001) but not the EILO group ( P > .05). Arytenoid prolapse occurred variably in both groups. Systolic blood pressure responses to exercise were higher in the control group, and heart rate recovery was faster in the EILO group. However, no significant differences were seen between the 2 groups on either autonomic parameter ( P > .05). CONCLUSIONS "Paradoxical" inspiratory and blunted expiratory vocal fold pattern responses to exercise best characterize EILO. Group differences were only seen with exercise challenge, thus highlighting the utility of provocation and control groups to identify EILO.
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Affiliation(s)
- Adrianna C Shembel
- 1 Department of Otolaryngology, NYU Langone Medical Center, Voice Center, New York, New York, USA.,2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA.,3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher J Hartnick
- 2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA
| | - Glenn Bunting
- 4 Massachusetts Eye and Ear, Voice and Speech Laboratory, Boston, Massachusetts, USA
| | - Catherine Ballif
- 4 Massachusetts Eye and Ear, Voice and Speech Laboratory, Boston, Massachusetts, USA
| | - Jessie Vanswearingen
- 3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Susan Shaiman
- 3 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aaron Johnson
- 1 Department of Otolaryngology, NYU Langone Medical Center, Voice Center, New York, New York, USA
| | - Vanessa de Guzman
- 2 Massachusetts Eye and Ear, Pediatric Airway, Voice, and Swallowing Center, Division of Pediatric Otolaryngology, Boston, Massachusetts, USA
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Christopher KL, Morris MJ. Vocal cord dysfunction, paradoxic vocal fold motion, or laryngomalacia? Our understanding requires an interdisciplinary approach. Otolaryngol Clin North Am 2010; 43:43-66, viii. [PMID: 20172256 DOI: 10.1016/j.otc.2009.12.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article presents disorders of periodic occurrence of laryngeal obstruction (POLO) resulting in noisy breathing and dyspnea and a variety of secondary symptoms. Included in this classification are glottic disorders, such as paradoxic vocal fold movement and vocal cord dysfunction. The supraglottic disorder, termed, intermittent arytenoid region prolapse or laryngomalacia, is also reviewed. Three categories of POLO are defined as irritant, exertional, and psychological.
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Affiliation(s)
- Kent L Christopher
- Department of Medicine, University of Colorado Health Sciences Center, Denver, CO 80231, USA.
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Abstract
The aryepiglottic folds extend between the arytenoid cartilage and the lateral margin of the epiglottis on each side and constitute the lateral borders of the laryngeal inlet. They are involved in physiologic closure mechanisms of the larynx and in pathologic conditions such as inspiratory stridor. Information on the normal topography of the aryepiglottic folds is poor and controversial. Therefore, this region was reinvestigated in serial whole-organ sections of 25 plastinated normal adult human larynges. Dorsally, the right and the left aryepiglottic folds are separated by the interarytenoid notch and comprise the corniculate and cuneiform cartilages, as well as numerous groups of mucous glands. Ventrally, the aryepiglottic folds are adjacent to the peri-epiglottic adipose tissue. Both regions are clearly separated by several layers of transversely oriented collagenous fiber layers. The muscular constituent of the aryepiglottic folds is only poorly developed, and no muscle fibers insert at the epiglottis. A coherent quadrangular membrane representing a ligamentous "skeleton" of the aryepiglottic folds is absent. A conspicuous collagenous fiber layer is found only to strengthen the free dorsal margin of the fold. Both muscular and ligamentous components may render the aryepiglottic folds sufficiently tense as to resist inspiratory inward suction in normal cases. However, pliability must be preserved to guarantee adequate folding in approximation of the aryepiglottic folds during deglutition. Thereby, the posterior part of the laryngeal inlet is closed, whereas the anterior part is probably closed by independent inward bulging of the peri-epiglottic adipose tissue.
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Affiliation(s)
- M M Reidenbach
- Department of Anatomy, Rheinische Friedrich-Wilhelms-Universität, Bonn, Germany
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Abstract
Vocal cord dysfunction (VCD), with its symptoms of stridor, air hunger, and chest or throat tightness, occurs primarily in active adolescents and young adults and may mimic exercise-induced asthma. Suspicions of VCD will be borne out by a mostly inspiratory stridor, abrupt onset and resolution of symptoms, an unpredictable symptom pattern, and the failure of usual asthma medications to resolve attacks. Laryngoscopy during acute symptoms is the definitive diagnostic tool. Panting can often stop an attack, and preventive treatment consists of patient education, speech therapy, and, when needed, psychological measures.
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Affiliation(s)
- S M Brugman
- National Jewish Medical and Research Center, Denver, CO, 80206, USA
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Talmi YP, Wolf M, Bar-Ziv J, Nusem-Horowitz S, Kronenberg J. Postintubation arytenoid subluxation. Ann Otol Rhinol Laryngol 1996; 105:384-90. [PMID: 8651633 DOI: 10.1177/000348949610500511] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Arytenoid subluxation (AS), ie, malpositioning of the arytenoid cartilage with abnormal but existent contact between the joint surfaces, is an uncommon entity, and fewer than 70 cases have been reported, 26 of which were in a recently published series. Usually, AS is the result of upper airway instrumentation, and only a few cases were reported to occur with external trauma to the neck. Some predisposing factors and possible mechanisms have been suggested, but the reason for its occurrence remains obscure. Hoarseness and, to a lesser degree, dysphagia, odynophagia, cough, and sore throat may be indicative of AS. Diagnosis is established by the clinical course, laryngoscopy, and computed tomography. Electromyography and strobovideolaryngoscopy are additional diagnostic measures described. We report 7 cases of postintubation AS of long standing. Three of these patients had prior unilateral vocal cord paralysis, formerly undescribed as a possible contributing factor for AS. The pertinent literature is reviewed and treatment options are discussed.
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Affiliation(s)
- Y P Talmi
- Department of Otolaryngology-Head and Neck Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Bittleman DB, Smith RJ, Weiler JM. Abnormal movement of the arytenoid region during exercise presenting as exercise-induced asthma in an adolescent athlete. Chest 1994; 106:615-6. [PMID: 7774352 DOI: 10.1378/chest.106.2.615] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
A 16-year-old female basketball player presented with a 2 1/2-year history of exercise-induced severe dyspnea, stridor, and mild wheezing that did not respond to prophylactic treatment with beta-agonists and cromolyn. Spirometric data at rest were normal, but flow-volume loops during exercise suggested a variable extrathoracic obstruction. Laryngoscopic evaluation while the patient was riding an exercise bicycle demonstrated an abnormal motion of the arytenoid region causing obstruction of the airway during inspiration. The vocal cords moved normally. This patient demonstrates the capacity of supraglottic tissue to obstruct the airway during exercise as a cause for exercise-induced dyspnea and stridor. Patients with this disorder may be misdiagnosed as having exercise-induced asthma.
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Affiliation(s)
- D B Bittleman
- Department of Internal Medicine, University of Iowa, Iowa City, USA
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Hayes JP, Nolan MT, Brennan N, FitzGerald MX. Three cases of paradoxical vocal cord adduction followed up over a 10-year period. Chest 1993; 104:678-80. [PMID: 8365274 DOI: 10.1378/chest.104.3.678] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Paradoxical vocal cord adduction (PVCA) is a rare disorder that may present with symptoms similar to asthma. Incorrect diagnosis may result in patients being unwittingly treated with prolonged high doses of antiasthma medication. PVCA probably forms part of a spectrum of uncommon and complex breathing disorders related to laryngeal dysfunction. Herein, we describe three cases of PVCA that illustrate the spectrum of clinical and physiologic presentation and the long-term natural history over a 10-year follow-up period. We conclude that PVCA, contrary to previous reports, is not always a benign condition; it may feature marked hypoxemia, fail to respond to previously advocated therapeutic strategies, and can persist on a long-term basis.
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Affiliation(s)
- J P Hayes
- Department of Respiratory Medicine, St Vincent's Hospital and University College, Dublin, Ireland
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