vocal cord dysfunction; inducible laryngeal obstruction
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Etiology
- paradoxical closure of the vocal cords during respirations
- adduction of vocal cords rather than abduction during inspiration[1]
- contributing factors
- physiologic response to underlying asthma
- reflex to protect airway in patient with chronic sinusitis & purulent postnasal drip
- severe esophageal reflux into larynx
- response to inhaled airway irritants
- may be triggered by exercise, irritants, or stress[4]
- psychiatric disorder - conversion disorder
Clinical manifestations
- wheezing (inspiratory & expiratory)
- dyspnea, shortness of breath exacerbated by exercise
- predominantly throat tightness, neck pain
- mid-chest tightness with exposure to triggers[1]
- hoarseness or dysphonia during symptomatic episodes
- laryngeal stridor
- symptoms are often worse during inspiration
- predominance of daytime symptoms; absence of night time awakenings
- onset may be abrupt; resolution may be abrupt[1]
- may be exacerbations & remissions
- anxiety[1]
- partial response to bronchodilators (asthma therapy)[1]
- acute asthma that improves immediately with endotracheal intubation[1]
Laboratory
- arterial blood gas
- normal A-a gradient despite profound respiratory distress
Diagnostic procedures
- pulmonary function testing
- abnormal flow-volume loop
- limitations in inspiration consistent with extra- thoracic obstruction
- inspiratory limb of the flow-volume loop is cut-off
- 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
- provocation with exercise or irritant exposure
Radiology
Differential diagnosis
- may mimic or co-exist with refractory asthma[4]
- may be misdiagnosed as anxiety
Management
- failure of response to high-dose glucocorticoids
- acute episodes respond to helium-oxygen mixture (70% helium, 30% oxygen)
- long term management
- reassurance
- withdrawal of unneeded asthma medications
- speech therapy
- laryngeal control techniques, biofeedback, relaxation
- treatment of underlying contributing factors
- psychiatric counseling
More general terms
More specific terms
Additional terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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: https://www.ncbi.nlm.nih.gov/pubmed/21330824
- ↑ Matrka L Paradoxic vocal fold movement disorder. Otolaryngol Clin North Am. 2014 Feb;47(1):135-46 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24286687
- ↑ 4.0 4.1 4.2 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/29066919 PMCID: PMC5644529 Free PMC article