Vocal cord dysfunction

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Vocal cord dysfunction
Classification and external resources
ICD-9 478.3-478.5

Vocal cord dysfunction (VCD) affects the vocal folds, commonly referred to as the vocal cords, and is characterized by full or partial vocal fold closure that usually occurs for short periods during inhalation but can occur during both inhalation and exhalation.[1] This closure may cause airflow obstruction but rarely results in reduction of oxygen saturation.

Presentation[edit]

Symptoms can include shortness of breath, dyspnea, wheezing, coughing, tightness in the throat, skin discoloration due to oxygen deprivation (cyanosis), noise during inhalation (stridor), and in severe cases, loss of consciousness.[2] The differential diagnosis for Vocal Cord Dysfunction, also referred to as paradoxical vocal fold motion (PVFM) and paradoxical vocal cord movement (PVCM), includes vocal fold swelling from allergy, asthma, or some obstruction of the vocal folds or throat. Anyone suspected of this condition should be evaluated and the vocal folds (voice box) visualized.
In individuals who experience a persistent difficulty with inhaling, consideration should be given to a neurological cause such as brain stem compression, cerebral palsy, etc.[3]
"Episodes" can be triggered suddenly or develop gradually and triggers are numerous. Primary causes are believed to be gastroesophageal reflux disease (GERD), extra-esophageal reflux (EERD), exposure to inhaled allergens, post nasal drip, exercise, or neurological conditions that can cause difficulty inhaling only during waking.[1] Published studies emphasize anxiety or stress as a primary cause while more recent literature indicates a likely physical etiology. This disorder has been observed from infancy through old age, with the observation of its occurrence in infants leading some to believe that a physiological cause such as reflux or allergy is likely. Certain medications, such as antihistamines for allergies, cause drying of the mucus membranes which can cause further irritation or hypersensitivity of the vocal cords.

VCD can mimic asthma, anaphylaxis, collapsed lungs, pulmonary embolism, or fat embolism, and can lead to an inaccurate diagnosis and inappropriate, potentially harmful, treatment.[4] Some are misdiagnosed with asthma, but are unresponsive to asthma therapy, including bronchodilators and steroids. Among adult patients, women tend to be diagnosed more often. Among children and teenage patients, VCD has been linked with high participation in competitive sports and family orientation towards high achievement.

Vocal cord dysfunction co-occurs with asthma approximately 40% of the time.[1] This frequently results in a misdiagnosis of only asthma. Even young children can tell the difference between an asthma attack (primarily difficulty exhaling) and a VCD attack (primarily difficulty inhaling). Knowing the difference between the two will help those who have both know when to use the rescue inhaler prescribed or when to use the breathing recovery exercises trained by a speech language pathologist.

Diagnosis[edit]

Vocal cord dysfunction is often diagnosed only after other potential conditions have been excluded and those suffering from it will have failed to respond to medication and other treatments before VCD is considered. This may mean several hospitalizations that are unresponsive to conventional treatments, such as asthma medication.

The most effective diagnostic strategy is to perform laryngoscopy during an episode at which time abnormal movement of the cords, if present, can be observed. If the endoscopy is not performed during an episode, it is likely that the vocal folds will be moving normally, a 'false negative' finding.

Spirometry may also be useful to establish the diagnosis of VCD when performed during a crisis or after a nasal provocation test.[5] With spirometry, just as the expiratory loop may show flattening or concavity when expiration is affected in asthma, so may the Inspiratory loop show truncation or flattening in VCD. Of course, testing may well be negative when symptoms are absent.[6]

Treatments[edit]

The first step to treat VCD is to stop unnecessary treatment. The use of steroids is not effective in VCD unless needed to treat underlying asthma and should be discontinued to avoid the morbidity associated with their use and to prevent severe long-term consequences, including growth retardation in children. Customary treatments are often multidisciplinary and include, in addition to breathing exercises by speech therapists, psychotherapy, behavioral therapy, use of anti-anxiety and anti-depressant medications, and hypnotherapy. There is no uniform approach and management should be individualized. The information from randomized, blinded studies is limited.[7]

Acute treatments can include heliox, intermittent positive pressure ventilation and continuous positive airway pressure. Severe cases may require a tracheotomy for temporary relief. Botox injections can also be made into the vocal folds.

If there is an underlying condition to which vocal cord dysfunction is secondary, it is important to treat the primary condition which alone can help with control.[2]

References[edit]

  1. ^ a b c Barbara A. Mathers-Schmidt Paradoxical Vocal Fold Motion: A Tutorial on a Complex Disorder and the Speech-Language Pathologist's Role Am J Speech Lang Pathol, May 2001; 10: 111 - 125.
  2. ^ a b Ibrahim WH, Gheriani HA, Almohamed AA, Raza T (Mar 2007). "Paradoxical vocal cord motion disorder: past, present and future". Postgrad Med J. 83(977): 164–172. PMC 2599980. PMID 17344570. 
  3. ^ Maschka DA, Bauman NM, McCray PB Jr, Hoffman HT, Karnell MP, Smith RJ (Nov 1997). "A classification scheme for paradoxical vocal cord motion". Laryngoscope. 107(11): 1429–35. PMID 9369385. 
  4. ^ Vlahakis, NE; Patel AM; Maragos NE; Beck KC (December 2002). "Diagnosis of vocal cord dysfunction: the utility of spirometry and plethysmography". Chest (American College of Chest Physicians) 122 (6): 2246–2249. doi:10.1378/chest.122.6.2246. PMID 12475872. 
  5. ^ Olivier CE, Argentão DGP, Lima RP, Silva MD, Santos RAPG. The nasal provocation test combined with spirometry establishes paradoxical vocal fold motion in allergic subjects. Allergy Asthma Proc 2013; 34:453-8. Pubmed
  6. ^ Weiss P, Rundell KW (Nov 2009). "Imitators of exercise-induced bronchoconstriction". Allergy Asthma Clin Immunol 5(1): 7. doi:10.1186/1710-1492-5-7. PMC 2794850. PMID 20016690. 
  7. ^ Guglani L, Atkinson S, Hosanagar A, Guglani L (August 2014). "A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction". Front Pediatr. PMC 4126208. PMID 25152871. 

External links[edit]