Vocal Cord Dysfunction

Aka: Vocal Cord Dysfunction, Paradoxical Vocal Cord Dysfunction, Paradoxical Vocal Fold Motion, Factitious Asthma, Munchausen's Stridor

1. See Also
   1. Dysphonia
2. Definition
   1. Inappropriate vocal cord motion transiently obstructs airway
   2. Vocal Cords remain in adduction despite inspiration
3. Symptoms
   1. Dyspnea
      1. Recurrent episodes
      2. Throat tightness
      3. Choking sensation
   2. Stridor
      1. Stridor may be mis-reported by patients as Wheezing
4. 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)
5. 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
6. 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
7. 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)
8. 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
9. 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
10. Management
    1. Deckert (2010) Am Fam Physician 81(2): 156-9 [PubMed]
    2. Mathers-Schmidt (2001) Am J Speech Lang Pathol 10(2): 111-25 [PubMed]
    3. Morris (2006) Clin Pulmonary Med 13(2): 73-86 [PubMed]
    4. Newsham (2002) J Athl Train 37(3): 325-8 [PubMed]