II. Definition

  1. Inappropriate vocal cord motion transiently obstructs airway
  2. Vocal Cords remain in adduction despite inspiration

III. Symptoms

  1. Dyspnea
    1. Recurrent episodes
    2. Throat tightness
    3. Choking sensation
  2. Stridor
    1. Stridor may be mis-reported by patients as Wheezing

IV. Causes: Precipitating factors of Vocal Cord Dysfunction

  1. Exercise
    1. May present as Exercise induced Asthma
  2. Psychiatric conditions
    1. Common in adolescents, but anxiety may also be triggered related to the unsettling nature of this condition
    2. Anxiety Disorder (e.g. Panic Attack, Generalized Anxiety Disorder, PTSD)
    3. Major Depression
  3. Environmental Irritants (airborne)
    1. Ammonia and other cleaning chemicals
    2. Dust
    3. Smoke
    4. Fumes
  4. Sinusitis
    1. Consider nasal steroid trial (e.g. Flonase)
    2. Consider antibiotic course
  5. Gastroesophageal Reflux disease
    1. Proton Pump Inhibitors are variably effective in improving Vocal Cord Dysfunction even when GERD is primary trigger
  6. Extrapyramidal Side Effects
    1. Focal Dystonic Reaction to Neuroleptic drugs (Antipsychotics)

V. Diagnostics

  1. Lateral Neck XRay
    1. Consider for evaluation of the epiglottis in the acute setting
  2. Pulmonary Function Test (PFT)
    1. Flow volume loop shows flattened inspiratory portion of the curve
  3. Nasolaryngoscopy (flexible Laryngoscopy)
    1. Diagnostic with direct visualization of the cords
    2. Directly observe abnormal vocal cord movement to the midline on inspiration or expiration
    3. Provocative maneuvers performed under direct visualization improve Test Sensitivity
      1. Panting
      2. Deep breathing
      3. Phonating

VI. Differential Diagnosis

  1. See Stridor
  2. Asthma (most common)
  3. Hypothyroidism
  4. Acute upper airway conditions
    1. Anaphylaxis or Angioedema
    2. Epiglottitis
    3. Croup
    4. Airway Foreign Body
  5. Chronic airway structural conditions
    1. Laryngomalacia (adults)
    2. Tracheal stenosis
  6. Other vocal cord specific disorders
    1. Vocal Cord Paralysis
    2. Vocal Cord Polyp and other vocal cord neoplasm

VII. Management: Emergency Department evaluation of undifferentiated Stridor

  1. See Awake Nasotracheal Intubation
  2. Maintain airway and consider differential diagnosis
  3. Ready all airway management equipment (RSI, intubation, failed airway)

VIII. Management: Short-Term symptomatic relief

  1. Remember that patients do not have volitional control over airway obstruction
  2. Be prepared for Advanced Airway and failed airway measures if case Stridor cause is not functional
  3. Maneuvers that help relieve acute symptoms
    1. Panting
    2. Diaphragmatic breathing
    3. Nasal breathing
    4. Breathing through a short straw
    5. Pursed-lip breathing
    6. Make hissing sound during expiration
  4. Other measures: Severe or persistent symptoms
    1. Epinephrine neb (5 ml of 1 mg/ml, 1:000 Epinephrine)
    2. Ipratropium Bromide (Atrovent) Inhaler
    3. Heliox
    4. Anxiolysis with Benzodiazepine (e.g. 1 mg Ativan)
    5. Ketamine
      1. Not studied, but has been used anecdotally with good success in acute severe Stridor
      2. Paradoxical Vocal Cord Dysfunction episodes often resolves (anecdotally) with Ketamine
      3. Ketamine may uncommonly cause laryngospasm (be ready with paralytics and Advanced Airway)
      4. Braude et al in Herbert (2015) EM Rap 15(2): 3-4

IX. Management: Long-Term elimination of underlying causes

  1. Treat causes above
    1. Consider Sinusitis Management (e.g. nasal steroid, antibiotic)
    2. Consider GERD management (e.g. Proton Pump Inhibitor)
    3. Eliminate airborne irritants
    4. Review possible medication triggers (e.g. Antipsychotic Medications)
  2. Speech therapy
    1. Relaxed throat breathing

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Ontology: Vocal Cord Dysfunction (C0859897)

Definition (MSH) A disorder characterized by an intermittent abnormal VOCAL CORDS movement toward the midline during inspiration or expiration resulting in upper AIRWAY OBSTRUCTION.
Concepts Finding (T033)
MSH D064706
SnomedCT 134290008
Dutch stembanddisfunctie
French Dysfonctionnement de corde vocale, Mouvement paradoxal d'adduction des cordes vocales, Mouvement paradoxal des cordes vocales, Dysfonction des cordes vocales, Adduction paradoxale des cordes vocales, Dysfonctionnement des cordes vocales
German Funktionsstoerung der Stimmbaender, Paradoxical vocal fold motion disorder, Paradoxical vocal cord dysfunction, Paradoxical vocal fold motion, Vocal cord dysfunction, Paradoxical vocal cord motion, Inspiratorischer Stimmritzenkrampf
Portuguese Disfunção das cordas vocais, Not Translated[Vocal Cord Dysfunction]
Spanish Disfunción de las cuerdas vocales, Not Translated[Vocal Cord Dysfunction], disfunción de la cuerda vocal (hallazgo), disfunción de la cuerda vocal
Japanese 声帯機能障害, セイタイキノウショウガイ
Czech Dysfunkce hlasivek, dysfunkce hlasivek, dysfunkce hlasových vazů
English cord dysfunction vocal, vocal cord dysfunction, Vocal Cord Dysfunctions, Vocal Cord Dysfunction, Dysfunction, Vocal Cord, Dysfunctions, Vocal Cord, Paradoxical Vocal Fold Motion, Paradoxical Vocal Fold Motion Disorder, Vocal Cord Dysfunction [Disease/Finding], Vocal cord dysfunction, Vocal cord dysfunction (finding)
Hungarian Hangszalag dysfunctio
Italian Disfunzione delle corde vocali, Disturbo motorio paradosso delle corde vocali
Norwegian Paradoksal stemmebåndsbevegelse, Stemmebåndsdysfunksjon
Russian ГОЛОСОВЫХ СВЯЗОК ДИСФУНКЦИЯ, GOLOSOVYKH SVIAZOK DISFUNKTSIIA