Vocal cord dysfunction
Encyclopedia
Vocal cord dysfunction is a condition that affects the vocal folds
, commonly referred to as the vocal cords, which is characterized by full or partial vocal fold closure that usually occurs during inhalation for short periods of time; however, can occur during both inhalation and exhalation.. This closure may cause airflow obstruction; however, rarely results in reduction of oxygen saturation.
, wheezing, coughing, tightness in the throat, skin discoloration due to oxygen deprivation, noise during inhalation stridor
, and in severe cases, loss of consciousness. The differential diagnosis for Vocal Cord Dysfunction, also referred to as paradoxical vocal fold motion (PVFM), includes vocal fold swelling from allergy, asthma, or some sort of obstruction of the vocal folds or throat area that may cause breathing difficulty. Anyone suspecting this condition should be evaluated by a physician and the vocal folds (voice box) should be looked at to rule out any sort of obstruction that may create difficulty breathing.
For individuals who experience a persistent difficulty with inhaling, a neurological evaluation is warranted to discover if there is a neurologic cause for the breathing difficulty. Neurologic causes for persistent difficulty inhaling can include brain stem compression, cerebral palsy, etc.
VCD "episodes" can be triggered suddenly, or come on gradually. Many different things can trigger an episode. The primary causes for a VCD episode 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. Other published scientific articles emphasize anxiety or stress as the primary cause; however, more recent literature indicates a likely physical etiology
for this disorder. This disorder has been observed throughout the lifespan, from infants through old age, with the observation of its occurrence in infants leading clinicians to believe that a physiological cause is likely, such as reflux or allergy.
This syndrome can mimic asthma
, anaphylaxis
, collapsed lungs, pulmonary embolism
, or fat embolism
, and can lead to an inaccurate diagnosis and inappropriate treatment which may be harmful to the patient. Many VCD patients are diagnosed 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. 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 an experienced speech language pathologist.
medication.
The most effective way of diagnosing VCD is to perform a nasal endoscopy during an episode. A clinician can then view the movement of the vocal folds and determine whether there is any abnormality. If the endoscopy
is not performed during an episode, it is likely that the vocal folds are moving normally and the clinician will not detect an abnormality. However, in severe cases, VCD is detectable outside of episode by observing persistent swelling of the vocal folds and indications of irritation.
Some acute treatments can be to use heliox
, Intermittent positive pressure ventilation, Continuous positive airway pressure
, and breathing exercise.
Some long term treatments include using Speech therapy, botox injections into the vocal folds, severe cases may require tracheotomy
for temporary relief.
If there is an underlying condition to which vocal cord dysfunction is secondary, it is important to treat the primary condition. This alone can help control VCD.
Vocal folds
The vocal folds, also known commonly as vocal cords, are composed of twin infoldings of mucous membrane stretched horizontally across the larynx...
, commonly referred to as the vocal cords, which is characterized by full or partial vocal fold closure that usually occurs during inhalation for short periods of time; however, can occur during both inhalation and exhalation.. This closure may cause airflow obstruction; however, rarely results in reduction of oxygen saturation.
Presentation
Symptoms can include shortness of breath DyspneaDyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
, wheezing, coughing, tightness in the throat, skin discoloration due to oxygen deprivation, noise during inhalation stridor
Stridor
Stridor is a high pitched wheezing sound resulting from turbulent air flow in the upper airway. Stridor is a physical sign which is produced by narrow or obstructed airway path. It can be inspiratory, expiratory or biphasic . Inspiratory stridor is common...
, and in severe cases, loss of consciousness. The differential diagnosis for Vocal Cord Dysfunction, also referred to as paradoxical vocal fold motion (PVFM), includes vocal fold swelling from allergy, asthma, or some sort of obstruction of the vocal folds or throat area that may cause breathing difficulty. Anyone suspecting this condition should be evaluated by a physician and the vocal folds (voice box) should be looked at to rule out any sort of obstruction that may create difficulty breathing.
For individuals who experience a persistent difficulty with inhaling, a neurological evaluation is warranted to discover if there is a neurologic cause for the breathing difficulty. Neurologic causes for persistent difficulty inhaling can include brain stem compression, cerebral palsy, etc.
VCD "episodes" can be triggered suddenly, or come on gradually. Many different things can trigger an episode. The primary causes for a VCD episode 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. Other published scientific articles emphasize anxiety or stress as the primary cause; however, more recent literature indicates a likely physical etiology
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
for this disorder. This disorder has been observed throughout the lifespan, from infants through old age, with the observation of its occurrence in infants leading clinicians to believe that a physiological cause is likely, such as reflux or allergy.
This syndrome can mimic asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
, anaphylaxis
Anaphylaxis
Anaphylaxis is defined as "a serious allergic reaction that is rapid in onset and may cause death". It typically results in a number of symptoms including throat swelling, an itchy rash, and low blood pressure...
, collapsed lungs, pulmonary embolism
Pulmonary embolism
Pulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...
, or fat embolism
Fat embolism
A fat embolism is a type of embolism that is often caused by physical trauma such as fracture of long bones, soft tissue trauma and burns.-Presentation:...
, and can lead to an inaccurate diagnosis and inappropriate treatment which may be harmful to the patient. Many VCD patients are diagnosed 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. 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 an experienced speech language pathologist.
Diagnosis
Vocal cord dysfunction is often diagnosed after all other potential conditions are ruled out. Patients must be unresponsive to medication and other potential treatments before VCD will be considered. This often means that the patient has been hospitalized on several occasions due to episodes that are unresponsive to "normal" treatments, such as asthmaAsthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
medication.
The most effective way of diagnosing VCD is to perform a nasal endoscopy during an episode. A clinician can then view the movement of the vocal folds and determine whether there is any abnormality. If the endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
is not performed during an episode, it is likely that the vocal folds are moving normally and the clinician will not detect an abnormality. However, in severe cases, VCD is detectable outside of episode by observing persistent swelling of the vocal folds and indications of irritation.
Treatments
The first step to treat VCD is to stop any unnecessary treatment. The use of steroids is not effective in VCD unless needed to treat underlying asthma. The drugs should be discontinued to avoid the morbidity associated with their use and to prevent severe long-term consequences, including growth retardation in children. Speech therapy is the first line of treatment for VCD and by itself is sometimes sufficient to correct the disorder.Some acute treatments can be to use heliox
Heliox
Heliox is a breathing gas composed of a mixture of helium and oxygen .Heliox has been used medically since the 1930s, and although the medical community adopted it initially to alleviate symptoms of upper airway obstruction, its range of medical uses has since expanded greatly, mostly because of...
, Intermittent positive pressure ventilation, Continuous positive airway pressure
Continuous positive airway pressure
Positive airway pressure is a mode of respiratory ventilation used primarily in the treatment of sleep apnea, for which it was first developed. PAP ventilation is also commonly used for those who are critically ill in hospital with respiratory failure, and in newborn infants...
, and breathing exercise.
Some long term treatments include using Speech therapy, botox injections into the vocal folds, severe cases may require tracheotomy
Tracheotomy
Among the oldest described surgical procedures, tracheotomy consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea...
for temporary relief.
If there is an underlying condition to which vocal cord dysfunction is secondary, it is important to treat the primary condition. This alone can help control VCD.