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Vocal Cord Dysfunction

BASICS

DESCRIPTION

- Pulmonary function testing with flow volume loop - Most commonly used test - Positive findings consist of normal expiratory volume loop with a flattened inspiratory volume loop. This is consistent with extrathoracic upper airway obstruction (6)[C]. - May require exercise testing for patients in whom exercise is the trigger - Useful for distinguishing from asthma, which may show a scooped expiratory loop

- Short term - Asthma control/treatment with appropriate meds, if coexisting (3)[C] - Reassurance and relaxation techniques: - Pursing lips - Panting (rapid, shallow breathing) - Diaphragmatic breathing - Breathing through the nose or a straw - Exhaling with a hissing sound

  • Vocal cord dysfunction (VCD): a breathing disorder in which vocal cords adduct inappropriately primarily on inspiration, producing airflow obstruction that may result in dyspnea, wheezing, and stridor
  • Synonym(s): paradoxical vocal fold motion (PVFM)

EPIDEMIOLOGY

Incidence

Not well defined ‚

Prevalence

  • Unknown; likely uncommon in the general population
  • Most frequently diagnosed in patients evaluated for asthma and exercise-induced dyspnea
  • Female predominance, 2:1 (1)
  • 71% of patients are adults and 29% of patients <18 years of age. Also has been diagnosed in young children/infants (1)
  • Suspect occurrence in approximately 3% of intercollegiate athletes with exercise-induced asthma (2).

ETIOLOGY AND PATHOPHYSIOLOGY

  • Exact etiology is unclear " ”both organic and nonorganic causes have been identified.
  • Possible laryngeal hyperresponsiveness to irritants, such as smoke, dust, postnasal drip, gastroesophageal reflux disease (GERD), URI, or other irritants (3)
  • Noncompetitive and competitive exercises " ”unknown mechanism (4)
  • Psychological factors such as anxiety, severe social stresses (e.g., competitive sports), history of sexual abuse (2)

Genetics

None defined ‚

RISK FACTORS

See "Commonly Associated Conditions. " ť ‚

COMMONLY ASSOCIATED CONDITIONS

  • Asthma
  • GERD
  • Rhinosinusitis
  • Psychological conditions such as posttraumatic stress disorder, anxiety, depression, and panic disorder

DIAGNOSIS

HISTORY

  • Recurrent episodes of "difficulty breathing in, " ť wheezing, throat or chest tightness, choking sensation, stridor, panic, and agitation
  • Stridulous sounds that are loudest above the throat, less audible throughout the chest wall.
  • Some patients (typically elite athletes) experience inspiratory stridor that resolves spontaneously when activity ceases.
  • The stridor is often mistaken for wheezing, leading to misdiagnosis of asthma or exercise-induced asthma.
  • Dysphonia or aphonia is possible between attacks.
  • History of multiple ED visits, possibly multiple intubations
  • The symptoms tend to be relatively mild but can be prolonged and severe.
  • Patients may report their asthma medications do not help their symptoms.

PHYSICAL EXAM

  • Inspiratory stridor
  • Cough
  • Wheezing (especially if unresponsive to bronchodilators)
  • Mild respiratory distress

DIFFERENTIAL DIAGNOSIS

  • Asthma: primary differential diagnosis because wheezing is a big component " ”although VCD can coexist with asthma (1,2). The key differences between the two are the following:Asthma typically has wheeze on expiration, VCD on inspiration.Asthma symptoms associated with nocturnal awakenings, uncommon in VCDAsthma is not typically associated with a sensation of choking.Asthma symptoms usually improve with albuterol use (3).VCD causes more difficulty with inspiration rather than expiration.VCD is not responsive to asthma treatment (unless coexisting) (2).
  • Anaphylaxis
  • Foreign body
  • Laryngeal angioedema
  • Chronic obstructive pulmonary disease
  • Epiglottitis
  • Vocal cord polyps/tumor
  • Vocal cord paralysis
  • Croup
  • Tracheal stenosis or masses
  • Laryngomalacia (1)
  • Neurologic cause: vagus or recurrent laryngeal nerve injury, amyotrophic lateral sclerosis (3)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Flexible laryngoscopy " ”gold standard (2)[C]Allows for direct visualization of abnormal adduction of the vocal cordsMay allow for diagnosis in more than half of asymptomatic patients; however, provocation tests such as methacholine (5), exercise (4), and histamine may be needed for diagnosis (4,5)[C].
  • Pulmonary function testing with flow volume loopMost commonly used testPositive findings consist of normal expiratory volume loop with a flattened inspiratory volume loop. This is consistent with extrathoracic upper airway obstruction (6)[C].May require exercise testing for patients in whom exercise is the triggerUseful for distinguishing from asthma, which may show a scooped expiratory loop
  • ImagingChest radiographs to rule out other causes of dyspnea (2)High-resolution CT of upper airways to evaluate for stenosis, masses (if not able to visualize trachea during laryngoscopy) (7)
  • Arterial blood gasesUseful to rule out other causes of severe respiratory distress

TREATMENT

GENERAL MEASURES

  • Short termAsthma control/treatment with appropriate meds, if coexisting (3)[C]Reassurance and relaxation techniques:Pursing lipsPanting (rapid, shallow breathing)Diaphragmatic breathingBreathing through the nose or a strawExhaling with a hissing soundContinuous positive airway pressure (CPAP)Intermittent CPAP with heliox (helium-oxygen) mixture may reduce airway resistance in some patients (1,2)[C].Anxiolytics if associated with anxiety attack (must confirm normal oxygen saturation prior to administration)Intubation with severe symptoms (3)[C]
  • Long termAvoid triggers.Behavioral speech/voice therapy (8)[B]Treat underlying conditions.

MEDICATION

First Line

No medications are specifically helpful. Exercise-induced VCD may respond to anticholinergics in addition to speech therapy; thus, consider a trial of ipratropium if symptoms are exercise-induced (9)[C]. ‚

ISSUES FOR REFERRAL

  • Diagnosis and treatment may require assistance of pulmonologist, otolaryngologist, allergist, psychiatrist, and/or psychologist.
  • Speech therapy is the mainstay of long-term treatment for patients with ongoing symptoms. It helps reduce recurrence.

ONGOING CARE

PROGNOSIS

Spontaneous resolution is common. ‚

REFERENCES

11 Morris ‚ MJ, Allan ‚ PF, Perking ‚ PJ. Vocal cord dysfunction: etiologies and treatment. Clin Pulm Med. 2006;13(2):73 " “86.22 Ibrahim ‚ WH, Gheriani ‚ HA, Almohamed ‚ AA, et al. Paradoxical vocal cord motion disorder: past, present and future. Postgrad Med J. 2007;83(977):164 " “172.33 Gimenez ‚ LM, Zafra ‚ H. Vocal cord dysfunction: an update. Ann Allergy Asthma Immunol. 2011;106(4):267 " “274.44 Chiang ‚ T, Marcinow ‚ AM, deSilva ‚ BW, et al. Exercise-induced paradoxical vocal fold motion disorder: diagnosis and management. Laryngoscope. 2013;123(3):727 " “731.55 Perkins ‚ PJ, Morris ‚ MJ. Vocal cord dysfunction induced by methacholine challenge testing. Chest. 2002;122(6):1988 " “1993.66 Mobeireek ‚ A, Alhamad ‚ A, Al-Subaei ‚ A, et al. Psychogenic vocal cord dysfunction simulating bronchial asthma. Eur Respir J. 1995;8(11):1978 " “1981.77 Lee ‚ KS, Boiselle ‚ PM. Update on multidetector computed tomography imaging of the airways. J Thorac Imaging. 2010;25(2):112 " “124.88 Sullivan ‚ MD, Heywood ‚ BM, Beukelman ‚ DR. A treatment for vocal cord dysfunction in female athletes: an outcome study. Laryngoscope. 2001;111(10):1751 " “1755.99 Doshi ‚ DR, Weinberger ‚ MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006;96(6):794 " “799.

ADDITIONAL READING

  • Deckert ‚ J, Deckert ‚ L. Vocal cord dysfunction. Am Fam Physician. 2010;81(2):156 " “159.
  • Jain ‚ S, Bandi ‚ V, Zimmerman ‚ J, et al. Incidence of vocal cord dysfunction in patients presenting to emergency room with acute asthma exacerbation. Chest. 1997;116(Suppl 2):243S.
  • Newsham ‚ KR, Klaben ‚ BK, Miller ‚ VJ, et al. Paradoxical vocal-cord dysfunction: management in athletes. J Athl Train. 2002;37(3):325 " “328.
  • Pargeter ‚ NJ, Mansur ‚ AH. The effectiveness of speech and language therapy in vocal cord dysfunction. Thorax. 2006;61(Suppl 2):ii126.
  • Weir ‚ M. Vocal cord dysfunction mimics asthma and may respond to heliox. Clin Pediatr (Phila). 2002;41(1):37 " “41.

CODES

ICD10

  • J38.3 Other diseases of vocal cords
  • J38.00 Paralysis of vocal cords and larynx, unspecified
  • J38.1 Polyp of vocal cord and larynx
  • J38.01 Paralysis of vocal cords and larynx, unilateral
  • J38.02 Paralysis of vocal cords and larynx, bilateral

ICD9

  • 478.5 Other diseases of vocal cords
  • 478.30 Paralysis of vocal cords or larynx, unspecified
  • 478.4 Polyp of vocal cord or larynx
  • 478.31 Unilateral paralysis of vocal cords or larynx, partial
  • 478.33 Bilateral paralysis of vocal cords or larynx, partial
  • 478.34 Bilateral paralysis of vocal cords or larynx, complete
  • 478.32 Unilateral paralysis of vocal cords or larynx, complete

SNOMED

  • 134290008 vocal cord dysfunction (finding)
  • 302912005 Vocal cord palsy (disorder)
  • 9078005 polyp of vocal cord (disorder)

CLINICAL PEARLS

  • Always consider VCD in poorly controlled asthmatics.
  • A multidisciplinary approach may be required for diagnosis and treatment.
  • Speech therapy is the mainstay of long-term treatment.