Fluoroscopic diagnosis of laryngeal asthma (paradoxical vocal cord motion)

Evidence-Based Systematic Review: Effects of Speech-Language Pathology Treatment for Individuals With Paradoxical Vocal Fold Motion

PURPOSE

In this article, our goal was to determine the state of the evidence and the effect of speech-language pathology (SLP) treatment for individuals with paradoxical vocal fold motion (PVFM).

METHOD

The American Speech-Language-Hearing Association's National Center for Evidence-Based Practice in Communication Disorders searched 22 electronic databases using key words related to PVFM, speech or voice treatment, and behavioral intervention for articles published through July 2013. Identified articles were systematically evaluated to assess the quality of the evidence using a modification of the American Speech-Language-Hearing Association's critical appraisal scheme.

RESULTS

Sixty-five articles met the search criteria. Only 2 out of the 65 articles were judged to contain adequate evidence to evaluate the effect of SLP treatment for PVFM. All 65 articles exemplify the state of the evidence for SLP treatment for PVFM.

CONCLUSION

The state of the evidence for the use of SLP treatment is in its infancy, with a majority of articles in the exploratory stage of research. Consequently, few clinical implications can be drawn at this time. SLP treatment for PVFM is promising; however, there is clearly a pressing need for systematic experimental studies that involve a control group to further the evidence base.

Diagnostic criteria for the classification of vocal cord dysfunction

Vocal cord dysfunction (VCD) is a syndrome characterized by paroxysms of glottic obstruction due to true vocal cord adduction resulting in symptoms such as dyspnea and noisy breathing. Since first described as a distinct clinical entity in 1983, VCD has inadvertently become a collective term for a variety of clinical presentations due to glottic disorders. Despite an increased understanding of laryngeal function over the past 25 years, VCD remains a poorly understood and characterized entity. Disparities in the literature regarding etiology, pathophysiology, and management may be due to the historic approach to this patient population. Additionally, disorders clearly not due to paroxysms of true vocal cord adduction, such as laryngomalacia, vocal cord paresis, and CNS causes, need to be differentiated from VCD. Although a psychologic origin for VCD has been established, gastroesophageal reflux disease (GERD), nonspecific airway irritants, and exercise have also been associated with intermittent laryngeal obstruction with dyspnea and noisy breathing. VCD has been repeatedly misdiagnosed as asthma; however, the relationship between asthma and VCD is elusive. There are numerous case reports on VCD, but there is a paucity of prospective studies. Following an in-depth review of the medical literature, this article examines the available retrospective and prospective evidence to present an approach for evaluation of VCD including: (1) evaluation of factors associated with VCD, (2) differential diagnosis of movement disorders of the upper airway, and (3) clinical, spirometric, and endoscopic criteria for the diagnosis.

Paradoxical vocal cord motion disorder: past, present and future

Paradoxical vocal cord motion disorder (PVCM), also called vocal cord dysfunction, is an important differential diagnosis for asthma. The disorder is often misdiagnosed as asthma leading to unnecessary drug use, very high medical utilisation and occasionally tracheal intubation or tracheostomy. Laryngoscopy is the gold standard for diagnosis of PVCM. Speech therapy and psychotherapy are considered the cornerstone of management of this disorder. The aim of this article is to increase the awareness of PVCM among doctors, highlighting the main characteristics that distinguish it from asthma and discuss the recent medical achievements and the possible future perspectives related to this disorder.

Laryngeal dyskinesia: an under-recognized condition

OBJECTIVE

To perform a review of the epidemiology, pathogenesis, clinical presentation, diagnosis and management of laryngeal dyskinesia.

METHODS

A search of the Medline database from 1966 to 2003 was performed. A manual search was performed of the references of each article.

RESULTS

Laryngeal dyskinesia is a respiratory condition characterized by abnormal vocal cord adduction and airflow limitation at the level of the larynx in the absence of evidence of local organic disease. It typically presents to the ED as wheeze, stridor or apparent upper airway obstruction. It occurs across a wide age range, is more common in females, and is typically associated with a range of underlying psychopathologies. Diagnosis is often delayed and unnecessary emergency treatment such as intubation and tracheostomy is not uncommon. Patients are commonly on high-dose steroids and are frequent users of the health-care system, often over prolonged periods. There are multiple diagnostic features on history and examination, and flexible nasendoscopy of the vocal cords in the ED can be used to confirm the diagnosis. Treatment options in the ED include sedation and use of continuous positive airway pressure. Long-term treatment involves a multidisciplinary approach involving respiratory physicians/ear, nose and throat surgeons, speech therapy and psychiatry.

CONCLUSION

Laryngeal dyskinesia remains an under-appreciated cause of respiratory presentations to the ED. Emergency physicians are ideally placed to make the diagnosis and initiate appropriate referral for specific therapies that have a high level of success.

Methacholine challenge testing in the diagnosis of paradoxical vocal fold motion

OBJECTIVE

The purpose of this study was to determine whether methacholine challenge testing (MCT) combined with serial laryngoscopy could elicit and visualize paradoxical vocal fold motion (PVFM) during asymptomatic periods and suggest laryngeal dysfunction as an etiology of episodic dyspnea.

STUDY DESIGN

A retrospective study of seven adult patients.

METHODS

Medical records of seven adult patients who were referred to an otolaryngology clinic with recurrent episodes of dyspnea or choking and underwent bronchoprovocation testing were reviewed. After initial fiberoptic laryngoscopy and pulmonary function testing (PFT), bronchoprovocation was performed using aerosolized methacholine at increasing concentrations. Each administration was followed by repeated laryngoscopy and PFT. A positive endoscopic test was marked by the visualization of paradoxical adduction of the true vocal folds during inspiration. A positive bronchoprovocation test was marked by a 20% or greater decline in the forced expiratory volume.

RESULTS

All seven patients demonstrated normal upper airway anatomy and function on initial laryngoscopy. In three patients, a positive endoscopic examination demonstrating PVFM was elicited during MCT. In three, the bronchoprovocation test was positive, and asthma was diagnosed. In one patient, both tests were negative. PVFM was seen in all patients whose chief complaint was choking (n = 2) but in only one of five patients whose chief complaint was dyspnea.

CONCLUSIONS

PVFM may be elicited and observed during MCT coupled with serial laryngoscopy. This test holds promise in differentiating vocal cord dysfunction from asthma during asymptomatic periods in patients who present with recurrent episodes of refractory dyspnea.

Cough and paradoxical vocal fold motion

OBJECTIVES

The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause.

STUDY DESIGN AND SETTING

We conducted a review of the literature.

METHODS

We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion.

RESULTS

The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patient's reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists.

CONCLUSION

Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients.

Occupational upper airway disease

The upper airway plays a critical role in filtering and conditioning air for the lungs. It provides the first line of warning and defense against microbials, allergens, and toxic inhalants. Current evidence suggests that the upper airway is susceptible to many of the pathogenic processes that the agents cause in the lower respiratory tract. Work-related rhinosinusitis or vocal cord dysfunction should prompt physicians and employers to identify the injurious agent(s) and formulate strategies to eliminate or reduce such exposures. Improving the work environment will prevent the development of new cases and the worsening of symptoms in existing cases.

Wheezing and vocal cord dysfunction mimicking asthma

Vocal cord dysfunction (VCD) is a respiratory disorder characterized by paradoxical closure of the vocal cords during the respiratory cycle leading to obstructive airway symptoms. The presenting symptoms vary from stridor to wheezing. VCD may coexist with asthma or masquerade as asthma. Misdiagnosis of VCD as asthma leads to inappropriate use of systemic steroids with its adverse effects, frequent emergency department visits, hospitalization, and, rarely, intubation and tracheostomy. Attenuation of the inspiratory flow volume loop on spirometry is suggestive of VCD. Laryngoscopic demonstration of the paradoxical vocal cord movements during an acute attack is the gold standard for the diagnosis of VCD. Patient education, speech therapy, and psychologic counseling are the therapeutic tools for treatment.

Psychogenic Respiratory Distress: A Case of Paradoxical Vocal Cord Dysfunction and Literature Review

BACKGROUND: Pulmonary disease such as asthma is a psychosomatic disorder vulnerable to exacerbations precipitated by psychological factors. A case is described in which a patient thought to have treatment-refractory asthma was discovered to have a conversion reaction, specifically paradoxical vocal cord dysfunction (PVCD), characterized by abnormal vocal cord adduction during inspiration. DATA SOURCES: Reports of PVCD were located using a MEDLINE search and review of bibliographies. MEDLINE (English language only) was searched from 1966 through December 1998 using the terms functional asthma, functional upper airway obstruction, laryngeal diseases, Munchausen's stridor, paradoxical vocal cord dysfunction, psychogenic stridor, respiratory stridor, vocal cord dysfunction, and vocal cord paralysis. A total of 170 cases of PVCD were reviewed. STUDY FINDINGS: PVCD appears to be significantly more common among females. PVCD spans all age groups, including pediatric, adolescent, and adult patients. PVCD was most often misdiagnosed as asthma or upper airway disease. Because patients present with atypical and/or refractory symptoms, several diagnostic tests are employed to evaluate patients with PVCD; laryngoscopy is the most common. Direct visualization of abnormal vocal cord movement is the most definitive means of establishing the diagnosis of PVCD. A number of psychiatric disturbances are related to PVCD, including conversion and anxiety disorders. PVCD is associated with severe psychosocial stress and difficulties with modulation of intense emotional states. CONCLUSIONS: Psychogenic respiratory distress produced by PVCD can be easily misdiagnosed as severe or refractory asthma or other pulmonary disease states. Recognition of PVCD is important to avoid unnecessary medications and invasive treatments. Primary care physicians can detect cases of PVCD by attending to clinical symptoms, implementing appropriate laboratory investigations, and examining the psychological covariates of the disorder. Psychotherapy and speech therapy are effective in treating most cases of PVCD.

Vocal cord dysfunction: don't mistake it for asthma

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.