vocal cord dysfunction

vocal cord dysfunction; inducible laryngeal obstruction

Etiology: 1) paradoxical closure of the vocal cords during respirations - adduction of vocal cords rather than abduction during inspiration [1] 2) contributing factors a) physiologic response to underlying asthma b) reflex to protect airway in patient with chronic sinusitis & purulent postnasal drip c) severe esophageal reflux into larynx d) response to inhaled airway irritants e) may be triggered by exercise, irritants, or stress [4] f) psychiatric disorder - conversion disorder 1] depression 2] obsessive-compulsive disorder 3] somatization disorder 4] post-traumatic stress disorder 5] history of sexual or physical abuse Clinical manifestations: 1) wheezing (inspiratory & expiratory) - inspiratory monophonic wheezing - monophonic inspiratory stridor 2) dyspnea, shortness of breath exacerbated by exercise 3) predominantly throat tightness, neck pain - mid-chest tightness with exposure to triggers [1] 4) hoarseness or dysphonia during symptomatic episodes 5) laryngeal stridor 6) symptoms are often worse during inspiration 7) predominance of daytime symptoms; absence of night time awakenings 8) onset may be abrupt; resolution may be abrupt [1] 9) may be exacerbations & remissions 10) anxiety [1] 11) partial response to bronchodilators (asthma therapy) [1] 12) acute asthma that improves immediately with endotracheal intubation [1] Laboratory: - arterial blood gas - normal A-a gradient despite profound respiratory distress Special laboratory: 1) pulmonary function testing a) abnormal flow-volume loop b) limitations in inspiration consistent with extra- thoracic obstruction c) inspiratory limb of the flow-volume loop is cut-off 2) laryngoscopy while patient is experiencing symptoms - provocation with exercise or irritant exposure - methacholine challenge negative - paradoxical approximation of the anterior 2/3 of the vocal cords & a small posterior opening (abnormal adduction) - adduction of the vocal cords during inspiration Radiology: - chest X-ray: no hyperinflation Differential diagnosis: - may mimic or co-exist with refractory asthma [4] - may be misdiagnosed as anxiety Management: 1) failure of response to high-dose glucocorticoids 2) acute episodes respond to helium-oxygen mixture (70% helium, 30% oxygen) 3) long term management a) reassurance b) withdrawal of unneeded asthma medications c) speech therapy - laryngeal control techniques, biofeedback, relaxation d) treatment of underlying contributing factors 1] chronic sinusitis with postnasal drip 2] gastroesophageal reflux e) psychiatric counseling

Specific

spasmodic dysphonia (laryngeal dystonia) vocal cord paralysis

General

laryngeal disease

References

Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
Benninger C, Parsons JP, Mastronarde JG Vocal cord dysfunction and asthma. Curr Opin Pulm Med. 2011 Jan;17(1):45-9 PMID: 21330824
Matrka L Paradoxic vocal fold movement disorder. Otolaryngol Clin North Am. 2014 Feb;47(1):135-46 PMID: 24286687
Lee J, Denton E, Hoy R et al. Paradoxical vocal fold motion in difficult asthma is associated with dysfunctional breathing and preserved lung function. J Allergy Clin Immunol Pract 2020 March 12 PMID: 32173506 https://www.sciencedirect.com/science/article/abs/pii/S2213219820302385 - Stojanovic S, Denton E, Lee J et al. Diagnostic and therapeutic outcomes following systematic assessment of patients with concurrent suspected vocal cord dysfunction and asthma. J Allergy Clin Immunol Pract 2022 Feb; 10:602-608.e1 PMID: 34718212 https://www.jaci-inpractice.org/article/S2213-2198(21)01191-0/fulltext
Fretzayas A, Moustaki M, Loukou I, Douros K. Differentiating vocal cord dysfunction from asthma. J Asthma Allergy. 2017 Oct 12;10:277-283 PMID: 29066919 PMCID: PMC5644529 Free PMC article

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