Vocal Cord Dysfunction

Aka: Vocal Cord Dysfunction, Paradoxical Vocal Cord Dysfunction, Paradoxical Vocal Fold Motion, Factitious Asthma

1. Definition
   1. Inappropriate vocal cord motion transiently obstructs airway
2. Symptoms
   1. Dyspnea
      1. Recurrent episodes
      2. Throat tightness
      3. Choking sensation
   2. Wheezing
      1. Stridor may be mis-reported by patients as Wheezing
3. 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)
4. Diagnostics
   1. Pulmonary Function Test (PFT)
      1. Flow volume loop shows flattened inspiratory portion of the curve
   2. 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
5. Differential Diagnosis
   1. Asthma (most common)
   2. Hypothyroidism
   3. Acute upper airway conditions
      1. Anaphylaxis or Angioedema
      2. Epiglottitis
      3. Croup
      4. Airway Foreign Body
   4. Chronic airway structural conditions
      1. Laryngomalacia (adults)
      2. Tracheal stenosis
   5. Other vocal cord specific disorders
      1. Vocal Cord Paralysis
      2. Vocal Cord Polyp and other vocal cord neoplasm
6. Management: Short-Term symptomatic relief
   1. Maneuvers that help relieve acute symptoms
      1. Panting
      2. Diaphragmatic breathing
      3. Nasal breathing
      4. Breathing through straw
      5. Pursed-lip breathing
      6. Make hissing sound during expiration
   2. Other measures: Severe or persistent symptoms
      1. Ipratropium Bromide (Atrovent) inhaler
      2. Heliox
7. 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
8. Management
   1. Deckert (2010) Am Fam Physician 81(2): 156-9
   2. Mathers-Schmidt (2001) Am J Speech Lang Pathol 10(2): 111-25
   3. Morris (2006) Clin Pulmonary Med 13(2): 73-86
   4. Newsham (2002) J Athl Train 37(3): 325-8