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Vocal Cord Dysfunction
Aka: Vocal Cord Dysfunction, Paradoxical Vocal Cord Dysfunction, Paradoxical Vocal Fold Motion, Factitious Asthma, Munchausen's Stridor, Functional Dysphonia, Spasmodic Dysphonia, Episodic Laryngeal Dyskinesia, Psychosomatic Stridor, Inducible Laryngeal Obstruction
- See Also
- Dysphonia
- Functional Aphonia
- Definitions
- Vocal Cord Dysfunction
- Inappropriate vocal cord motion transiently obstructs airway
- Vocal Cords remain in adduction despite inspiration
- Epidemiology
- Peak age 30-40 years
- Gender: Female predominance (2-3 fold more than males)
- Pathophysiology
- Inducible Laryngeal Obstruction
- Paradoxical vocal cord closure (e.g. during inspiration) resulting in impaired respiration and altered voice
- Symptoms
- Hoarseness, Dysphonia or Aphonia
- Associated with less severe episodes
- Dyspnea
- Recurrent episodes
- Throat tightness
- Chest tightness
- Choking Sensation
- Stridor
- Stridor may be mis-reported by patients as Wheezing
- Signs
- View patient obtained video if available as exam is typically normal outside of episodes
- Sudden onset of severe Dyspnea without associated Hypoxia, Tachypnea or increased work of breathing
- Inspiratory Stridor
- Causes: Precipitating factors of Vocal Cord Dysfunction
- Exercise
- May present as Exercise induced Asthma
- Psychiatric conditions
- Common in adolescents, but anxiety may also be triggered related to the unsettling nature of this condition
- Anxiety Disorder (e.g. Panic Attack, Generalized Anxiety Disorder, PTSD, Performance Anxiety)
- Major Depression
- Obsessive Compulsive Disorder
- Environmental Irritants (airborne)
- Ammonia and other cleaning chemicals
- Dust
- Smoke
- Fumes
- Sinusitis or recent Upper Respiratory Infection
- Consider nasal steroid trial (e.g. Flonase)
- Consider antibiotic course
- Gastroesophageal Reflux disease
- Proton Pump Inhibitors are variably effective in improving Vocal Cord Dysfunction even when GERD is primary trigger
- Extrapyramidal Side Effects
- Focal Dystonic Reaction to Neuroleptic drugs (Antipsychotics)
- Associated Conditions
- Asthma (25-30% of cases)
- Gastroesophageal Reflux
- Anxiety Disorder
- Imaging
- Chest XRay
- Evaluate differential diagnosis (upper chest mass resulting in compression)
- Lateral Neck XRay
- Consider for evaluation of the epiglottis in the acute setting
- Diagnostics
- Pulmonary Function Test (PFT)
- Flow volume loop shows flattened inspiratory portion of the curve
- FEF50/FIF50 >1
- Where FEF50 is Expiratory Flow at 50% of Forced Vital Capacity (FVC)
- Where FIF50 is Inspiratory Flow at 50% of Forced Vital Capacity (FVC)
- Consider Methacholine Challenge
- Evaluate for Asthma in differential diagnoses
- Nasolaryngoscopy (flexible Laryngoscopy)
- Diagnostic with direct visualization of the cords
- Directly observe abnormal vocal cord movement to the midline on inspiration or expiration
- Provocative maneuvers performed under direct visualization improve Test Sensitivity
- Panting
- Exercise
- Deep breathing
- Phonating
- Differential Diagnosis
- See Stridor
- Asthma (most common)
- Hypothyroidism
- Acute upper airway conditions
- Anaphylaxis or Angioedema
- Epiglottitis
- Croup
- Airway Foreign Body
- Chronic airway structural conditions
- Laryngomalacia (adults)
- Subglottic Stenosis or Tracheal stenosis
- Tracheal Mass
- Vocal cord specific disorders
- Vocal Cord Paralysis
- Vocal Cord Polyp and other vocal cord neoplasm
- Other neurologic conditions
- Amyotrophic Lateral Sclerosis
- Vagus Nerve Injury
- Recurrent Laryngeal Nerve Injury
- Management: Emergency Department evaluation of undifferentiated Stridor
- See Awake Nasotracheal Intubation
- Maintain airway and consider differential diagnosis
- Ready all airway management equipment (RSI, intubation, failed airway)
- Evaluate and manage acute Asthma
- Management: Short-Term symptomatic relief
- Remember that patients do not have volitional control over airway obstruction
- Be prepared for Advanced Airway and failed airway measures if case Stridor cause is not functional
- Maneuvers that help relieve acute symptoms
- Panting
- Diaphragmatic breathing
- Nasal breathing
- Breathing through a short straw
- Pursed-lip breathing
- Make hissing sound during expiration
- "Rescue Breaths" Technique
- https://www.youtube.com/watch?v=cKHd935oRBg
- Other measures: Severe or persistent symptoms
- Epinephrine neb (5 ml of 1 mg/ml, 1:000 Epinephrine)
- Ipratropium Bromide (Atrovent) Inhaler
- Heliox
- Anxiolysis with Benzodiazepine (e.g. 1 mg Ativan)
- Ketamine
- Not studied, but has been used anecdotally with good success in acute severe Stridor
- Paradoxical Vocal Cord Dysfunction episodes often resolves (anecdotally) with Ketamine
- Ketamine may uncommonly cause laryngospasm (be ready with paralytics and Advanced Airway)
- Braude et al in Herbert (2015) EM Rap 15(2): 3-4
- Management: Long-Term elimination of underlying causes
- Treat causes above
- Consider Sinusitis Management (e.g. nasal steroid, antibiotic)
- Consider GERD management (e.g. Proton Pump Inhibitor)
- Eliminate airborne irritants
- Review possible medication triggers (e.g. Antipsychotic Medications)
- Manage Asthma
- Speech therapy
- Therapeutic breathing Exercises including relaxed throat breathing
- Vocal cord Relaxation Techniques
- Otolaryngology Consultation
- Consider Botox Injection for Spasmodic Dysphonia
- Management
- Deckert (2010) Am Fam Physician 81(2): 156-9 [PubMed]
- Malaty (2021) Am Fam Physician 104(5): 471-5 [PubMed]
- Mathers-Schmidt (2001) Am J Speech Lang Pathol 10(2): 111-25 [PubMed]
- Morris (2006) Clin Pulmonary Med 13(2): 73-86 [PubMed]
- Newsham (2002) J Athl Train 37(3): 325-8 [PubMed]