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Yi JS, Davis AC, Pietsch K, Walsh JM, Scriven KA, Mock J, Ryan MA. Demographic Differences in Clinical Presentation of Pediatric Paradoxical Vocal Fold Motion (PVFM). J Voice 2024; 38:539.e1-539.e9. [PMID: 34642070 DOI: 10.1016/j.jvoice.2021.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Paradoxical vocal fold motion (PVFM) is involuntary closure of the vocal folds during inspiration, often presenting in children and young adults. Although common symptoms and triggers are known, differences in clinical presentation based on patient demographics are unknown. This study characterizes differences in clinical presentation of pediatric PVFM based on age, sex, and race/ethnicity. METHODS We reviewed electronic medical records of patients 0-21 years old with PVFM based on ICD codes from 2009 to 2019 within a tertiary academic health system. Demographics, symptoms, triggers, concurrent diagnoses, and laryngoscopy findings were abstracted. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression. RESULTS Among 96 individuals the mean age was 10.6 years (standard deviation ±6.5) and 66 (69%) were female. In comparison to 13-21 year olds, those 0-2 years more often had PVFM observed on laryngoscopy (OR = 17.84, 95% CI: 3.14-101.51) and had less shortness of breath (OR = 0.01, 95% CI: 0.00-0.09). Those 3-12 years had more asthma (OR = 3.07, 95% CI: 1.07-8.81) and cough (OR = 6.12, 95% CI: 1.77-21.13). Both 0-2 (OR = 0.07, 95% CI: 0.02-0.24) and 3-12 year olds (OR = 0.13, 95% CI: 0.04-0.40) presented less with activity as a trigger. Racial/ethnic minorities were more likely to present with pharyngeal findings (eg mucosal inflammation, adenotonsillar hypertrophy) on laryngoscopy (OR = 4.58, 95% CI: 1.45-15.37) compared to non-Hispanic Whites. Differences in clinical presentation by sex were not observed. CONCLUSION We identified several differences in symptoms, triggers, and laryngoscopy findings in pediatric PVFM based on age and race/ethnicity. Associations between sex and clinical presentation were not observed.
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Affiliation(s)
- Julie S Yi
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ashley C Davis
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kristine Pietsch
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan M Walsh
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kelly A Scriven
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeremy Mock
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marisa A Ryan
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Otolaryngology - Head and Neck Surgery, Emory Voice Center, Emory University, Medical Office Tower, Atlanta, Georgia.
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Ambati SR, Kaslovsky R, Evans MT, Edge W. Vocal Cord Dysfunction During the COVID-19 Pandemic. Respir Care 2023; 68:520-523. [PMID: 36810361 PMCID: PMC10173119 DOI: 10.4187/respcare.10408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
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.
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Affiliation(s)
- Shashikanth R Ambati
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical College, Albany, New York.
| | - Robert Kaslovsky
- Division of Pediatric Pulmonology, Department of Pediatrics, Albany Medical College, Albany, New York
| | - Mary T Evans
- Division of Pediatric Pulmonology, Department of Pediatrics, Albany Medical College, Albany, New York
| | - Walter Edge
- Division of Pediatric Pulmonology, Department of Pediatrics, Albany Medical College, Albany, New York
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Stojanovic S, Denton E, Lee J, Tay TR, Murthee KG, Mahoney J, Hoy R, Hew M. Diagnostic and Therapeutic Outcomes Following Systematic Assessment of Patients with Concurrent Suspected Vocal Cord Dysfunction and Asthma. J Allergy Clin Immunol Pract 2021; 10:602-608.e1. [PMID: 34718212 DOI: 10.1016/j.jaip.2021.10.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/12/2021] [Accepted: 10/12/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vocal cord dysfunction (VCD) is present in 25% to 50% of patients with asthma. When both diagnoses are suspected, accurate diagnosis and targeted management represent a clinical challenge. OBJECTIVE To evaluate diagnostic and therapeutic outcomes following systematic assessment for patients with concurrent suspected VCD and asthma. METHODS Patients underwent systematic evaluation by clinical assessment and validated questionnaires, followed by multidisciplinary management. VCD was confirmed by visualization of paradoxical vocal fold motion at baseline or following provocation. Asthma was confirmed by demonstrating variable airflow obstruction. Asthma medications were deescalated in those with low clinical probability of asthma and no variable airflow obstruction. Response to 2 or more sessions of speech pathology was assessed by subjective report and standardized questionnaires. RESULTS Among 212 consecutive patients, 62 (29%) patients had both VCD and asthma, 54 (26%) had VCD alone, 51 (24%) had asthma alone, and 45 (21%) had neither. Clinician assessment and the Laryngeal Hypersensitivity Questionnaire both predicted laryngoscopy-confirmed VCD. Deescalation or discontinuation of asthma therapy was possible in 37 of 59 (63%) patients without variable airflow obstruction, and was most successful (odds ratio, 5.5) in the presence of laryngoscopy-confirmed VCD (25 of 31, or 81%) Patients with VCD responded subjectively to 2 or more sessions of speech pathology, but laryngeal questionnaire scores did not improve. CONCLUSIONS Expert clinician assessment and the Laryngeal Hypersensitivity Questionnaire predict the presence of laryngoscopy-confirmed VCD. Systematic assessment for both VCD and asthma facilitates deescalation or discontinuation of unnecessary asthma medications. Subjective symptom improvement following speech pathology was not paralleled by laryngeal questionnaire scores in this cohort.
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Affiliation(s)
- Stephanie Stojanovic
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Joy Lee
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Janine Mahoney
- Speech Pathology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ryan Hoy
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Bonati E, Bignami EG, Del Rio P. Postoperative vocal fold dysfunction in covid-19 era: are we still in time for a recovery? Endocrine 2020; 70:11-12. [PMID: 32772337 PMCID: PMC7415190 DOI: 10.1007/s12020-020-02433-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/21/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Elena Bonati
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Parma, Italy.
| | - Elena Giovanna Bignami
- Unit of Anesthesiology, Department of Medicine and Surgery, Parma University Hospital, Parma, Italy
| | - Paolo Del Rio
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Parma, Italy
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Lee J, Denton E, Hoy R, Tay TR, Bondarenko J, Hore-Lacy F, Radhakrishna N, O'Hehir RE, Dabscheck E, Abramson MJ, Hew M. Paradoxical Vocal Fold Motion in Difficult Asthma Is Associated with Dysfunctional Breathing and Preserved Lung Function. J Allergy Clin Immunol Pract 2020; 8:2256-2262. [PMID: 32173506 DOI: 10.1016/j.jaip.2020.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/13/2020] [Accepted: 02/23/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many patients with difficult asthma also have coexisting vocal cord dysfunction (VCD), evident by paradoxical vocal fold motion (PVFM) on laryngoscopy. OBJECTIVE Among patients with difficult asthma, we sought to identify clinical features associated with laryngoscopy-diagnosed PVFM. METHODS Consecutive patients with "difficult asthma" referred by respiratory specialists underwent systematic assessment in this observational study. Those with a high clinical suspicion for VCD were referred for laryngoscopy, either at rest or after mannitol provocation. Statistical analyses were performed to identify clinical factors associated with PVFM, and a multivariate logistic regression model was fitted to control for confounders. RESULTS Of 169 patients with difficult asthma, 63 (37.3%) had a high clinical probability of VCD. Of 42 who underwent laryngoscopy, 32 had PVFM confirmed. Patients with PVFM more likely had preserved lung function (prebronchodilator forced expiratory ratio 74% ± 11 vs 62% ± 16, P < .001); physiotherapist-confirmed dysfunctional breathing (odds ratio [OR] = 5.52, 95% confidence interval [CI]: 2.4-12.7, P < .001), gastro-oesophageal reflux (OR = 2.6, 95% CI: 1.16-5.8, P = .02), and a lower peripheral eosinophil count (0.09 vs 0.23, P = .004). On multivariate logistic regression, independent predictors for PVFM were dysfunctional breathing (OR = 4.93, 95% CI: 2-12, P < .001) and preserved lung function (OR = 1.07, 95% CI: 1.028-1.106, P < .001). CONCLUSION Among specialist-referred patients with difficult asthma, VCD pathogenesis may overlap with dysfunctional breathing but is not associated with severe airflow obstruction. Dysfunctional breathing and preserved lung function may serve as clinical clues for the presence of VCD.
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Affiliation(s)
- Joy Lee
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ryan Hoy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tunn Ren Tay
- Department of Respiratory & Critical Care Medicine, Changi General Hospital, Singapore
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Respiratory Medicine, Allergy and Clinical Immunology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael J Abramson
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Hamdan AL, Mourad M, Fakhri G, Sarieddine D, Khalifee E, Azar ST. Vocal tract symptoms: Severity and frequency in patients on statins. Ear Nose Throat J 2018; 97:128-136. [PMID: 29940682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
The objective of the study was to analyze the frequency and severity of vocal tract symptoms in patients on statins. A total of 73 patients were enrolled in this study, 44 patients who were taking statins and 29 controls not taking statins. The severity and frequency of vocal tract discomfort was assessed using the Vocal Tract Discomfort scale. The most frequent vocal tract symptom in patients on statins was dryness followed by tightness and lump sensation. The difference in the mean of the total score and in the mean frequency of any vocal tract symptom was not significant between patients taking statins and controls. The most severe (highest mean values) vocal tract symptom in patients taking statins also was dryness followed by tightness and lump sensation. The difference in the mean of the total score and in the mean severity of any vocal tract symptom between patients taking statins and controls was not significant. This study failed to demonstrate a higher prevalence or severity of vocal tract symptoms in patients receiving statins. Despite the lack of a significant difference in the means of vocal tract discomfort symptom frequency and severity, this study carries clinical significance when considering that a higher prevalence and severity of vocal tract discomfort symptoms should alert physicians to the possible development of statin-induced myotoxicity in the laryngopharyngeal complex.
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Affiliation(s)
- Abdul-Latif Hamdan
- Department of Internal Medicine, American University of Beirut Medical Center, Lebanon
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Heck S, Al-Shobash S, Rapp D, Le DD, Omlor A, Bekhit A, Flaig M, Al-Kadah B, Herian W, Bals R, Wagenpfeil S, Dinh QT. High probability of comorbidities in bronchial asthma in Germany. NPJ Prim Care Respir Med 2017; 27:28. [PMID: 28432297 PMCID: PMC5435094 DOI: 10.1038/s41533-017-0026-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 03/02/2017] [Accepted: 03/21/2017] [Indexed: 12/19/2022] Open
Abstract
UNLABELLED Clinical experience has shown that allergic and non-allergic respiratory, metabolic, mental, and cardiovascular disorders sometimes coexist with bronchial asthma. However, no study has been carried out that calculates the chance of manifestation of these disorders with bronchial asthma in Saarland and Rhineland-Palatinate, Germany. Using ICD10 diagnoses from health care institutions, the present study systematically analyzed the co-prevalence and odds ratios of comorbidities in the asthma population in Germany. The odds ratios were adjusted for age and sex for all comorbidities for patients with asthma vs. without asthma. Bronchial asthma was strongly associated with allergic and with a lesser extent to non-allergic comorbidities: OR 7.02 (95%CI:6.83-7.22) for allergic rhinitis; OR 4.98 (95%CI:4.67-5.32) allergic conjunctivitis; OR 2.41 (95%CI:2.33-2.52) atopic dermatitis; OR 2.47 (95%CI:2.16-2.82) food allergy, and OR 1.69 (95%CI:1.61-1.78) drug allergy. Interestingly, increased ORs were found for respiratory diseases: 2.06 (95%CI:1.64-2.58) vocal dysfunction; 1.83 (95%CI:1.74-1.92) pneumonia; 1.78 (95%CI:1.73-1.84) sinusitis; 1.71 (95%CI:1.65-1.78) rhinopharyngitis; 2.55 (95%CI:2.03-3.19) obstructive sleep apnea; 1.42 (95%CI:1.25-1.61) pulmonary embolism, and 3.75 (95%CI:1.64-8.53) bronchopulmonary aspergillosis. Asthmatics also suffer from psychiatric, metabolic, cardiac or other comorbidities. Myocardial infarction (OR 0.86, 95%CI:0.79-0.94) did not coexist with asthma. Based on the calculated chances of manifestation for these comorbidities, especially allergic and respiratory, to a lesser extent also metabolic, cardiovascular, and mental disorders should be taken into consideration in the diagnostic and treatment strategy of bronchial asthma. BRONCHIAL ASTHMA PREVALENCE OF CO-EXISTING DISEASES IN GERMANY: Patients in Germany with bronchial asthma are highly likely to suffer from co-existing diseases and their treatments should reflect this. Quoc Thai Dinh at Saarland University Hospital in Homburg, Germany, and co-workers conducted a large-scale study of patients presenting with bronchial asthma in the Saarland region between 2009 and 2012. Patients with asthma made up 5.4% of the region's total population, with a higher prevalence occurring in females. They found that bronchial asthma was strongly associated with allergic comorbidities such as rhinitis. Indeed, asthmatic patients had a seven times higher chance to suffer from allergic rhinitis than the rest of the population, and were at higher risk of respiratory diseases like pneumonia and obstructive sleep apnea syndrome. Further associations included cardiovascular, metabolic and mental disorders. Dinh's team call for asthma treatments to take such comorbidities into account.
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Affiliation(s)
- S Heck
- Department of Experimental Pneumology and Allergology, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - S Al-Shobash
- Department of Experimental Pneumology and Allergology, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - D Rapp
- Department of Biometry, Epidemiology and Clinical informatics, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - D D Le
- Department of Experimental Pneumology and Allergology, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - A Omlor
- Department of Experimental Pneumology and Allergology, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - A Bekhit
- Department of Biometry, Epidemiology and Clinical informatics, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - M Flaig
- Department of Internal Medicine V, Pneumology, Allergology and Respiratory Critical Care Medicine, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - B Al-Kadah
- Department of Otorhinolaryngology, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - W Herian
- Head of the Regulatory Management Division, Association of Statutory Health Insurance Physicians Saarland, Saarbrucken, Germany
| | - R Bals
- Department of Internal Medicine V, Pneumology, Allergology and Respiratory Critical Care Medicine, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - S Wagenpfeil
- Department of Biometry, Epidemiology and Clinical informatics, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Q T Dinh
- Department of Experimental Pneumology and Allergology, Saarland University Faculty of Medicine, Homburg/Saar, Germany.
- Department of Internal Medicine V, Pneumology, Allergology and Respiratory Critical Care Medicine, Saarland University Faculty of Medicine, Homburg/Saar, Germany.
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Abstract
Paradoxical Vocal Fold Movement Disorder (PVFMD) is a cause of dyspnea that can mimic or occur alongside asthma or other pulmonary disease. Treatment with Laryngeal Control Therapy is very effective once the entity is properly diagnosed and contributing comorbidities are managed appropriately. In understanding the etiology of PVFMD, focus has broadened beyond psychiatric factors alone to include the spectrum of laryngeal irritants (laryngopharyngeal reflux, allergic and sinus disease, sicca, and possibly obstructive sleep apnea). The following is a discussion of the history, terminology, epidemiology, diagnosis, comorbid conditions, and treatment of this entity.
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Affiliation(s)
- Laura Matrka
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Eye and Ear Institue, Suite 4000, 915 Olentangy River Road, Columbus, OH 43212, USA; JamesCare Voice and Swallowing Disorders Clinic, Stoneridge Medical Center, 4019 West Dublin-Granville Road, Dublin, OH 43017, USA.
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