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Alanazi A, Aizouki C, Sloychuk J, Callaghan A, Eksteen E, Ennis S, Isaac A. Optimizing the Diagnosis and Management of Pediatric Inducible Laryngeal Obstruction. Laryngoscope 2025; 135:1207-1211. [PMID: 39367750 PMCID: PMC11830960 DOI: 10.1002/lary.31818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 08/28/2024] [Accepted: 09/17/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND Pediatric inducible laryngeal obstruction (ILO) is difficult to diagnose and treat. Patients often undergo multiple specialist referrals, and long-term outcomes are not well reported. OBJECTIVES To investigate the patterns of presentation, workup, and management of children who were diagnosed with ILO at the Stollery Children's Hospital. METHODS Retrospective review with a prospective cohort of pediatric patients diagnosed with ILO from 2015 to 2023. We collected the demographic data, diagnostic tests, specialist referrals, time to diagnosis, symptom burden, associated comorbidities and aggravating factors, management, and treatment outcomes. A subset of patients was followed prospectively to determine treatment outcomes. A basic descriptive analysis was performed, and factors associated with time to resolution were studied. RESULTS Seventy-eight patients met the criteria for inclusion, with 22 completing prospective questionnaires. The average age was 14 years old, and 75% were female. The majority required multiple specialist referrals. The majority were associated with exercise. Thirty-two (41%) patients had a presumed diagnosis of asthma, despite only four pulmonary function tests being consistent with asthma. Abortive breathing exercises were the most commonly employed (95%) and most successful (61%) nonsurgical management technique. Surgery was highly successful in a small cohort of patients. Median time to symptom resolution was 12 months, with 36% reporting symptoms persistent beyond 3 years. CONCLUSIONS Pediatric ILO often goes undiagnosed for prolonged periods. Exercise-related symptoms are the most common. Management strategies have varied levels of success and a large proportion of patients have prolonged symptoms despite treatment, as supported by other recent evidence. LEVEL OF EVIDENCE 3 Laryngoscope, 135:1207-1211, 2025.
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Affiliation(s)
- Alaa Alanazi
- Division of Otolaryngology‐Head and Neck Surgery, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
| | - Carolin Aizouki
- Faculty of Medicine and Dentistry, College of Health SciencesUniversity of AlbertaEdmontonAlbertaCanada
| | - Janelle Sloychuk
- Division of Otolaryngology‐Head and Neck Surgery, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
| | - Amy Callaghan
- Division of Pediatric Surgery, Stollery Children's Hospital, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
| | - Eduard Eksteen
- Division of Otolaryngology‐Head and Neck Surgery, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
- Division of Pediatric Surgery, Stollery Children's Hospital, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
| | - Sheila Ennis
- Department of Rehabilitation MedicineStollery Children's HospitalEdmontonAlbertaCanada
| | - Andre Isaac
- Division of Otolaryngology‐Head and Neck Surgery, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
- Division of Pediatric Surgery, Stollery Children's Hospital, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
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Pascal ES, Maes AM, Hawley K. A retrospective review of infant-inducible laryngeal obstruction a subtype of paradoxical vocal fold motion: Evaluation and management. Am J Otolaryngol 2025; 46:104514. [PMID: 39700759 DOI: 10.1016/j.amjoto.2024.104514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 08/19/2024] [Accepted: 11/09/2024] [Indexed: 12/21/2024]
Abstract
INTRODUCTION There is a paucity of literature on pre-adolescent paradoxical vocal fold motion (PVFM), PVFM is a sub-type of inducible laryngeal obstruction. Studies typically focus on older patients, however the discovery of this entity in pre-adolescent pediatric patients has led to more questions about how this entity manifests differently and is treated differently in younger populations. Initially considered psychosomatic and commonly mistaken for asthma, PVFM etiology is now thought to be associated underlying neurologic conditions and may have irritant triggers with proposed mechanisms related to laryngeal hypersensitivity. Treatment is multimodal. Diagnosis is with flexible laryngoscopy and clinical exam but other modalities like functional endoscopic evaluation of swallow may provide more information than flexible laryngoscopy alone. METHODS After obtaining IRB approval, a retrospective review of all charts of patients ages 0-18 months (pre-adolescent pediatric patients) who underwent flexible endoscopic evaluation of swallow and/or flexible laryngoscopy from 1/2013-8/2021 was performed. Twenty-four subjects diagnosed with PVFM were identified. RESULTS The most common presenting symptom was stridor or coughing with feeds. 63 % were male, mean age at time of diagnosis was 3.4 months, and mean follow-up length was 11.4 months. Comorbidities included reflux (45 %), pulmonary diagnoses (25 %) and neurologic diagnoses (54 %). 16/24 subjects had otolaryngology diagnoses (laryngomalacia, tracheomalacia, subglottic stenosis, or ankyloglossia). 12/24 subjects were treated with conservative management such as anti-reflux medications or precautions. 33 % of patients treated with conservative management had complete symptom resolution. PVFM patients with neurologic comorbidities were more likely to require alternative feeding access (p < 0.05). All 11 subjects who required surgical feeding access had neurologic diagnoses. 5/10 of patients with neonatal abstinence syndrome (NAS) required alternative feeding means, and 40 % tolerated oral feeds after medical management of NAS. CONCLUSION Our findings suggest PVFM is most commonly seen in pre-adolescent pediatric patients with medical comorbidities. Healthy pre-adolescent pediatric patients with PVFM frequently improved with conservative management. The differential diagnosis of the stridulous infant should include PVFM. It is imperative to consider nutritional access in PVFM patients with neurologic comorbidities.
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Affiliation(s)
- Emily S Pascal
- Surgery, Division of Otolaryngology, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Aurora M Maes
- Surgery, Division of Otolaryngology, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Karen Hawley
- Surgery, Division of Otolaryngology, University of New Mexico Hospital, Albuquerque, NM, USA.
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Eapen AA, Gupta MR, Lockey RF, Bardin PG, Baptist AP. Gastroesophageal reflux disease, laryngopharyngeal reflux, and vocal cord dysfunction/inducible laryngeal obstruction-overlapping conditions that affect asthma. J Allergy Clin Immunol 2024; 154:1369-1377. [PMID: 39426423 DOI: 10.1016/j.jaci.2024.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 10/04/2024] [Accepted: 10/10/2024] [Indexed: 10/21/2024]
Abstract
Asthma is a chronic lung condition that may be affected by numerous medical comorbidities. Such comorbidities can influence the presentation and even the severity of asthma. Alternatively, asthma may be misdiagnosed as a comorbidity when symptoms overlap. The 3 medical conditions that commonly affect asthma management are gastroesophageal reflux disease, laryngopharyngeal reflux, and vocal cord dysfunction/inducible laryngeal obstruction). These conditions can be difficult to distinguish from one another, as well as from asthma itself. In this review, the epidemiology, pathophysiology, symptomatology, and diagnostic considerations of each condition in both adult and pediatric populations are discussed. Treatment options, as well as how such options may influence asthma outcomes, are included. Finally, knowledge gaps in each area are highlighted, as a better understanding of the optimal diagnostic and therapeutic approaches will allow for improved individualized care of patients with asthma.
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Affiliation(s)
- Amy A Eapen
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Henry Ford Health + Michigan State University, Detroit, Mich
| | - Meera R Gupta
- Division Immunology, Allergy, and Retrovirology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Richard F Lockey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Philip G Bardin
- Monash Lung Sleep Allergy & Immunology, Melbourne, Australia; Hudson Institute, Melbourne, Australia; Monash Hospital and University, Melbourne, Australia
| | - Alan P Baptist
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Henry Ford Health + Michigan State University, Detroit, Mich.
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Sandage MJ, Morton-Jones ME, Hall-Landers RJ, Tucker JG. Treatment and Outcome Metrics for Speech-Language Pathology Treatment of Upper Airway Disorders: A Systematic Review. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:4391-4410. [PMID: 39405507 DOI: 10.1044/2024_jslhr-24-00396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2024]
Abstract
OBJECTIVE Clinical treatment strategies and progress metrics for patients with inducible laryngeal obstruction (ILO) and exercise-induced laryngeal obstruction (EILO) have not been systematically applied across clinics. The goals of this review were to identify the intervention strategies used to treat upper airway disorders and determine the clinical metrics by which improvement or resolution of ILO/EILO is determined in clinical studies of speech-language pathology intervention. METHOD A systematic review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Systematic Reviews Checklist. English language, full-text publications were identified through MEDLINE (Ovid), APA PsycINFO, and Web of Science for publications that described clinical outcomes following behavioral treatment for ILO provided by a speech-language pathologist (SLP). RESULTS A total of 238 sources were retrieved, of which 75 were duplicates. Titles and abstracts of 163 were screened, with 22 sources included for full-text review. Citation review yielded nine additional resources. Thirty-one sources were included for data extraction. Most sources described use of respiratory/laryngeal retraining. There was a lack of consistency for clinical and standardized metrics used to evaluate improvement or resolution of upper airway symptoms. CONCLUSIONS Behavioral and standardized outcome metrics for evaluating therapy outcomes from SLP behavioral intervention of ILO/EILO are not consistently applied. Clinical metrics standards for clinicians are needed to provide a means to evaluate graded improvement in treatment and changes in health care utilization as well as for training less-experienced clinicians. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.27172683.
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Affiliation(s)
- Mary J Sandage
- Department of Speech, Language and Hearing Sciences, Auburn University, AL
| | | | | | - Jordan G Tucker
- Department of Speech, Language and Hearing Sciences, Auburn University, AL
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Luedders J, May S, Lyden E, Rorie A, Graaff JVD, Zamora-Sifuentes J, Walenz R, Poole JA. Age differences in inducible laryngeal obstruction in adult populations. Ann Allergy Asthma Immunol 2024; 133:574-580. [PMID: 39154909 DOI: 10.1016/j.anai.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/30/2024] [Accepted: 08/02/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Whereas differences in inducible laryngeal obstruction (ILO) presentation on the basis of age have been observed within pediatric populations, age-based differences in adult populations are lacking. OBJECTIVE To describe differences in ILO on the basis of age in adults. METHODS Patients aged older than 16 years with confirmed ILO (vocal cord adduction > 50% during inspiration) by means of provocation-challenge rhinolaryngoscopy by their treating allergist were included. An investigator-designed questionnaire was administered using Research Electronic Data Capture with corresponding medical data collection. χ2 tests, Student's t tests, analysis of variance, Cochran-Armitage test for trend, and Fisher's exact test were used. RESULTS The median age of the 67 patients was 50 years. P values less than .05 were considered significant. Those aged younger than 50 years (n = 31; mean age 35.6 years) reported more symptoms vs age 50 years and older (n = 36; mean age 61.8 years), including shortness of breath at rest and exertion (84% vs 39%, 94% vs 72%), throat tightness (81% vs 50%), chest tightness (81% vs 47%), and difficulty getting air in (81% vs 56%). Those aged younger than 50 years had an increased history of anxiety (68% vs 33%), asthma (55% vs 31%), positive methacholine challenge (52% vs 22%), increasing triggers with time (87% vs 43%), higher Pittsburgh Vocal Cord Dysfunction Index Scores (6.9 vs 5.5), and inspiratory curve flattening (48% vs 24%). Additional age-based subdivisions confirmed significant trends with the lowest reported ILO characteristics and symptoms in those aged 65 years and older. CONCLUSION A high index of suspicion for ILO should be maintained in older adults since they may report less typical ILO symptoms and anxiety associations that prompt ILO evaluation.
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Affiliation(s)
- Jennilee Luedders
- Division of Allergy and Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Sara May
- Division of Allergy and Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Elizabeth Lyden
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Andrew Rorie
- Division of Allergy and Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Joel Van De Graaff
- Division of Allergy and Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - José Zamora-Sifuentes
- Division of Allergy and Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Rhonda Walenz
- Division of Allergy and Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jill A Poole
- Division of Allergy and Immunology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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McConville KM, Thibeault SL. Patient perceptions of the impact of inducible laryngeal obstruction on quality of life. PLoS One 2024; 19:e0307002. [PMID: 39012891 PMCID: PMC11251631 DOI: 10.1371/journal.pone.0307002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 06/26/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Inducible laryngeal obstruction (ILO) accounts for or contributes to dyspnea in a noteworthy proportion of treatment seeking populations including those misdiagnosed with asthma. Despite increasing awareness of the disorder, literature exploring patient experience is limited. The aim of this work is to report patient perspectives on ILO and the way in which it impacts quality of life. METHODS This qualitative study utilized methods detailed in the literature on grounded theory and phenomenological research to analyze interviews collected from participants diagnosed with ILO. Interviews were conducted, audio recorded, and transcribed. Transcriptions underwent content-analysis using Burnard's 14 step method [15], which included review of content codes across multiple raters until consensus regarding analyses was reached. RESULTS Twenty-six participants were included in the study. Most participants were female (92%). Ages ranged from 18-72 with a mean age of 45 for female participants and 37 for male participants. Without specific prompting to do so, all participants offered descriptions of the specific symptoms they experienced and the triggers for their symptoms. In the content analysis process, "descriptions of symptoms and triggers" was thus labeled a theme that was present in all interviews. Seven additional themes were shared consistently and judged to encapsulate the interview material. These themes were: 2) diagnosis and treatment, 3) emotional impact of ILO, 4) perception of health and prognosis, 5) ameliorating factors, 6) influence of ILO on lifestyle, 7) the physical impact of ILO, and 8), social consequences of ILO. In addition, 54 subthemes were identified. CONCLUSIONS Patients appear to place particular emphasis on the emotional and psychosocial consequences of ILO as well as factors that ameliorate the condition. As such, future efforts to treat ILO and to collect outcomes measures should account for these aspects of the patient experience.
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Affiliation(s)
- Katherine M. McConville
- Department of Speech-Language Pathology, Michigan Medicine, The University of Michigan, Ann Arbor, Michigan, United States of America
| | - Susan L. Thibeault
- Division of Otolaryngology—Head and Neck Surgery, School of Medicine and Public Health, University of WisconsinMadison, Madison, Wisconsin, United States of America
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Young E, Watson W, Krishna P. Logical Fallacies in Missed Diagnosis of Stridorous Patients: A Case Report. Cureus 2024; 16:e62456. [PMID: 39015864 PMCID: PMC11250613 DOI: 10.7759/cureus.62456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2024] [Indexed: 07/18/2024] Open
Abstract
Tracheal stenosis and paradoxical vocal fold motion are both common laryngological diagnoses that can present with similar symptoms of dyspnea. Co-morbid psychiatric issues can complicate diagnostic accuracy and lead to logical fallacies in the attribution of symptom etiology. We present a case of a 38-year-old female who presented repeatedly to the emergency department with respiratory distress, inspiratory stridor, wheezing, and anxiety. On examination, she had stridor that appeared to correlate with episodes of elevated anxiety and bedside laryngoscopy which showed intermittent paradoxical vocal fold motion. A computed tomography scan showed 40% narrowing of the distal tracheal lumen, but symptoms were felt to be inconsistent and out of proportion to stenosis. She was seen several more times in the ED and eventually followed up in the laryngology clinic, where she had a tracheoscopy showing Cotton Meyer grade III stenosis. This unique case highlights the logical fallacies that may lead to misdiagnosis when evaluating stridorous patients with comorbid personality and anxiety disorders.
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Affiliation(s)
- Everett Young
- Otolaryngology, Loma Linda University School of Medicine, Loma Linda, USA
| | - WayAnne Watson
- Otolaryngology, Loma Linda University Medical Center, Loma Linda, USA
| | - Priya Krishna
- Otolaryngology, Loma Linda University Medical Center, Loma Linda, USA
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Karkouli G, Douros K, Moriki D, Moutsatsou P, Giannopoulou I, Maratou E, Koumpagioti D. Dysfunctional Breathing in Children: A Literature Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:556. [PMID: 38790551 PMCID: PMC11120484 DOI: 10.3390/children11050556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/22/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024]
Abstract
Dysfunctional breathing (DB) describes a respiratory condition that is mainly characterized by abnormal breathing patterns, affecting both children and adults, often leading to intermittent or chronic complaints and influencing physiological, psychological, and social aspects. Some symptoms include breathlessness; dizziness; palpitations; and anxiety, while its classification lies in breathing pattern disorders and upper airway involvement. Its prevalence among the pediatric population varies with a female overrepresentation, while the existence of comorbidities in DB, such as asthma, gastro-esophageal reflux, nasal diseases, and anxiety/depression, frequently leads to misdiagnosis or underdiagnosis and complicates therapeutic approaches. The basic diagnostic tools involve a detailed history, physical examination, and procedures such as structured light plethysmography, cardiopulmonary exercise testing, and laryngoscopy when a laryngeal obstruction is present. The management of DB presumes a multidimensional approach encompassing breathing retraining, disease-specific advice through speech and language therapy in the presence of laryngeal obstruction, psychotherapy for fostering self-efficacy, and surgical therapy in a structural abnormality. The current review was developed to provide a summary of classifications of DB and epidemiological data concerning the pediatric population, comorbidities, diagnostic tools, and therapeutic approaches to enhance the comprehension and management of DB in children.
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Affiliation(s)
- Georgia Karkouli
- Allergology and Pulmonology Unit, 3rd Pediatric Department, National and Kapodistrian University of Athens, 12462 Athens, Greece; (G.K.); (D.M.)
| | - Konstantinos Douros
- Allergology and Pulmonology Unit, 3rd Pediatric Department, National and Kapodistrian University of Athens, 12462 Athens, Greece; (G.K.); (D.M.)
| | - Dafni Moriki
- Allergology and Pulmonology Unit, 3rd Pediatric Department, National and Kapodistrian University of Athens, 12462 Athens, Greece; (G.K.); (D.M.)
| | - Paraskevi Moutsatsou
- Department of Clinical Biochemistry, National and Kapodistrian University of Athens, 12462 Athens, Greece; (P.M.); (E.M.)
| | - Ioanna Giannopoulou
- Department of Psychiatry, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Eirini Maratou
- Department of Clinical Biochemistry, National and Kapodistrian University of Athens, 12462 Athens, Greece; (P.M.); (E.M.)
| | - Despoina Koumpagioti
- Department of Nursing, National and Kapodistrian University of Athens, 11527 Athens, Greece;
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Yi JS, Davis AC, Pietsch K, Walsh JM, Scriven KA, Mock J, Ryan MA. Demographic Differences in Clinical Presentation of Pediatric Paradoxical Vocal Fold Motion (PVFM). J Voice 2024; 38:539.e1-539.e9. [PMID: 34642070 DOI: 10.1016/j.jvoice.2021.08.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Paradoxical vocal fold motion (PVFM) is involuntary closure of the vocal folds during inspiration, often presenting in children and young adults. Although common symptoms and triggers are known, differences in clinical presentation based on patient demographics are unknown. This study characterizes differences in clinical presentation of pediatric PVFM based on age, sex, and race/ethnicity. METHODS We reviewed electronic medical records of patients 0-21 years old with PVFM based on ICD codes from 2009 to 2019 within a tertiary academic health system. Demographics, symptoms, triggers, concurrent diagnoses, and laryngoscopy findings were abstracted. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression. RESULTS Among 96 individuals the mean age was 10.6 years (standard deviation ±6.5) and 66 (69%) were female. In comparison to 13-21 year olds, those 0-2 years more often had PVFM observed on laryngoscopy (OR = 17.84, 95% CI: 3.14-101.51) and had less shortness of breath (OR = 0.01, 95% CI: 0.00-0.09). Those 3-12 years had more asthma (OR = 3.07, 95% CI: 1.07-8.81) and cough (OR = 6.12, 95% CI: 1.77-21.13). Both 0-2 (OR = 0.07, 95% CI: 0.02-0.24) and 3-12 year olds (OR = 0.13, 95% CI: 0.04-0.40) presented less with activity as a trigger. Racial/ethnic minorities were more likely to present with pharyngeal findings (eg mucosal inflammation, adenotonsillar hypertrophy) on laryngoscopy (OR = 4.58, 95% CI: 1.45-15.37) compared to non-Hispanic Whites. Differences in clinical presentation by sex were not observed. CONCLUSION We identified several differences in symptoms, triggers, and laryngoscopy findings in pediatric PVFM based on age and race/ethnicity. Associations between sex and clinical presentation were not observed.
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Affiliation(s)
- Julie S Yi
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ashley C Davis
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kristine Pietsch
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan M Walsh
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kelly A Scriven
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeremy Mock
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marisa A Ryan
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Otolaryngology - Head and Neck Surgery, Emory Voice Center, Emory University, Medical Office Tower, Atlanta, Georgia.
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Gray AJ, Hoffman MR, Yang ZM, Vandiver B, Purvis J, Morgan JP, Hapner ER, Dominguez L, Tibbetts K, Simpson CB. Indications and Short-Term Outcomes for In-Office Therapeutic Superior Laryngeal Nerve Block. Ann Otol Rhinol Laryngol 2024; 133:174-180. [PMID: 37608685 PMCID: PMC10771019 DOI: 10.1177/00034894231194384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVE Superior laryngeal nerve (SLN) block consists of injection of steroid and anesthetic at the internal branch of the SLN entry site. Prior case series have demonstrated beneficial effects on neurogenic cough. SLN blocks have also recently shown benefit for paralaryngeal pain. We describe short-term outcomes for multiple symptoms of irritable larynx syndrome (ILS) including neurogenic cough, dysphonia related to laryngeal hypersensitivity, inducible laryngeal obstruction (ILO), paralaryngeal pain, and isolated globus. METHODS Retrospective review from 2 institutions of patients undergoing a single SLN block for the indications listed. Variables include age, sex, indication(s), known vagus neuropathy, and patient-reported outcomes at short-term follow-up. RESULTS A total of 209 patients were included (59 males, 150 females; age: 58 ± 13 years). Twenty-six patients (12%) had a history of a vagus nerve injury. Indications included neurogenic cough (n = 149), dysphonia related to laryngeal hypersensitivity (n = 66), paralaryngeal pain (n = 50), ILO (n = 23), and isolated globus (n = 3). Some patients had multiple indications. Significant improvements in patient-reported measures occurred after a single SLN block within 2 to 4 weeks for neurogenic cough (cough severity index; 25.2 ± 11.2 to 19.0 ± 12.8; P < .001), dysphonia (voice handicap index-10; 22.1 ± 12.2-18.0 ± 13.3; P = .005), and ILO (dyspnea index; 21.0 ± 14.9-14.7 ± 15.7; P = .017). Subjective pain improved in 23 of 39 patients with paralaryngeal pain. There was no observed improvement for isolated globus. Presence of known vagal neuropathy or therapy around the time of SLN block did not affect outcome. CONCLUSION SLN block can be an effective component of treatment for a variety of ILS symptoms. Patients may experience some improvement after 1 injection. LAY SUMMARY Symptoms of irritable larynx syndrome, such as neurogenic cough, paralaryngeal pain, inducible laryngeal obstruction, and dysphonia related to laryngeal hypersensitivity can be challenging to manage. In-office Superior Laryngeal Nerve blocks can serve as a quick, well tolerated, adjunctive treatment with positive short-term outcomes. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Alan J. Gray
- Department of Otolaryngology—Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Matthew R. Hoffman
- Department of Otolaryngology—Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
- Department of Otolaryngology—Head and Neck Surgery, University of Iowa, Iowa City, IA, USA
| | - Zao M. Yang
- Department of Otolaryngology—Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Beau Vandiver
- Department of Otolaryngology—Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Joshua Purvis
- Department of Otolaryngology—Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Jake P. Morgan
- Department of Otolaryngology—Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Edie R. Hapner
- Department of Otolaryngology—Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Laura Dominguez
- Department of Otolaryngology—Head and Neck Surgery, Cleveland Clinic Florida, Coral Springs, FL, USA
| | - Kathleen Tibbetts
- Department of Otolaryngology—Head and Neck Surgery, University of Texas-Southwestern, Dallas, TX, USA
| | - C. Blake Simpson
- Department of Otolaryngology—Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
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Fujiki RB, Fujiki AE, Thibeault SL. Examining therapy duration in adults with induced laryngeal obstruction (ILO). Am J Otolaryngol 2024; 45:104094. [PMID: 37948819 PMCID: PMC10842780 DOI: 10.1016/j.amjoto.2023.104094] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE This study examined the number of therapy sessions required to sufficiently improve (exercise) induced laryngeal obstruction (EILO/ILO) symptoms for discharge. Factors predicting therapy duration were examined as was the likelihood of patients returning for additional therapy sessions following initial discharge. METHODS Retrospective observational cohort design. Data for 350 patients were gathered from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. Patients (>18 years of age) diagnosed with EILO/ILO received therapy from a Speech-Language Pathologist (SLP) and were successfully discharged. EILO/ILO treatment details, symptoms, triggers, medical comorbidities, and patient demographics were collected from initial evaluations and subsequent course of therapy. RESULTS Patients required an average of 3.59 (SD = 3.7) therapy sessions prior to discharge. A comorbid behavioral health diagnosis (p = .026), higher Vocal Handicap Index Score (p = .009) and reduced physical activity due to EILO/ILO symptoms (p = .032) were associated with increased therapy duration. Patients with ILO or EILO with secondary environmental triggers required significantly more sessions than those with exercise-induced symptoms (p < .01). Eight percent of patients returned for additional sessions following discharge. Patients returning for additional sessions all came from affluent neighborhoods as measured by the Area Deprivation Index (ADI). CONCLUSIONS Patients with EILO/ILO required an average of 3.59 therapy sessions prior to discharge. As such, 4 sessions is a reasonable estimate for clinicians to provide patients. Six sessions may be a more conservative estimate for patients who present with a behavioral health diagnosis, a voice complaint, or reduced physical activity from EILO/ILO symptoms.
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Affiliation(s)
- Robert Brinton Fujiki
- Department of Surgery, University of Wisconsin Madison, Madison, WI, United States of America
| | - Amanda Edith Fujiki
- Division of Psychiatry, Child and Adolescent Division, University of Utah School of Medicine, SLC, UT, United States of America
| | - Susan L Thibeault
- Department of Surgery, University of Wisconsin Madison, Madison, WI, United States of America.
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12
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Leong P, Vertigan AE, Hew M, Baxter M, Phyland D, Hull JH, Carroll TL, Gibson PG, McDonald VM, Halvorsen T, Clemm HH, Vollsæter M, Røksund OD, Bardin PG. Diagnosis of vocal cord dysfunction/inducible laryngeal obstruction: An International Delphi Consensus Study. J Allergy Clin Immunol 2023; 152:899-906. [PMID: 37343843 DOI: 10.1016/j.jaci.2023.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/01/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is characterized by breathing difficulties in association with excessive supraglottic or glottic laryngeal narrowing. The condition is common and can occur independently; however, it may also be comorbid with other disorders or mimic them. Presentations span multiple specialties and misdiagnosis or delayed diagnosis is commonplace. Group-consensus methods can efficiently generate internationally accepted diagnostic criteria and descriptions to increase clinical recognition, enhance clinical service availability, and catalyze research. OBJECTIVES We sought to establish consensus-based diagnostic criteria and methods for VCD/ILO. METHODS We performed a modified 2-round Delphi study between December 7, 2021, and March 14, 2022. The study was registered at ANZCTR (Australian New Zealand Clinical Trials Registry; ACTRN12621001520820p). In round 1, experts provided open-ended statements that were categorized, deduplicated, and amended for clarity. These were presented to experts for agreement ranking in round 2, with consensus defined as ≥70% agreement. RESULTS Both rounds were completed by 47 international experts. In round 1, 1102 qualitative responses were received. Of the 200 statements presented to experts across 2 rounds, 130 (65%) reached consensus. Results were discussed at 2 international subject-specific conferences in June 2022. Experts agreed on a diagnostic definition for VCD/ILO and endorsed the concept of VCD/ILO phenotypes and clinical descriptions. The panel agreed that laryngoscopy with provocation is the gold standard for diagnosis and that ≥50% laryngeal closure on inspiration or Maat grade ≥2 define abnormal laryngeal closure indicative of VCD/ILO. CONCLUSIONS This Delphi study reached consensus on multiple aspects of VCD/ILO diagnosis and can inform clinical practice and facilitate research.
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Affiliation(s)
- Paul Leong
- Monash Lung Sleep Allergy & Immunology, Monash Health, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
| | - Anne E Vertigan
- Speech Pathology, John Hunter Hospital, Newcastle, Australia; Centre of Excellence in Treatable Traits, University of Newcastle, Newcastle, Australia
| | - Mark Hew
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; AIRMed, Alfred Hospital, Melbourne, Australia
| | - Malcolm Baxter
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Ear Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Debra Phyland
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Ear Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | | | - Thomas L Carroll
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Peter G Gibson
- Centre of Excellence in Treatable Traits, University of Newcastle, Newcastle, Australia; Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Vanessa M McDonald
- Centre of Excellence in Treatable Traits, University of Newcastle, Newcastle, Australia; Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Thomas Halvorsen
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway; Faculty of Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway; Faculty of Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Maria Vollsæter
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway; Faculty of Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway; Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Philip G Bardin
- Monash Lung Sleep Allergy & Immunology, Monash Health, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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13
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Fujiki RB, Olson-Greb B, Braden M, Thibeault SL. Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1517-1531. [PMID: 37195781 PMCID: PMC10473392 DOI: 10.1044/2023_ajslp-22-00359] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/16/2023] [Accepted: 03/07/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE This study examined treatment outcomes of speech-language pathology intervention addressing exercise-induced laryngeal obstruction (EILO) symptoms in teenage athletes. METHOD A prospective cohort design was utilized; teenagers diagnosed with EILO completed questionnaires during initial EILO evaluations, posttherapy, 3-month posttherapy, and 6-month posttherapy. Questionnaires examined the frequency of breathing problems, the use of the techniques taught in therapy, and the use of inhaler. Patients completed the Pediatric Quality of Life (PedsQL) inventory at all time points. RESULTS Fifty-nine patients completed baseline questionnaires. Of these, 38 were surveyed posttherapy, 32 at 3-month posttherapy, and 27 at 6-month posttherapy. Patients reported more frequent and complete activity participation immediately posttherapy (p = .017) as well as reduced inhaler use (p = .036). Patients also reported a significant reduction in the frequency of breathing problems 6-month posttherapy (p = .015). Baseline PedsQL physical and psychosocial scores were below normative range and were not impacted by therapy. Baseline physical PedsQL score significantly predicted frequency of breathing difficulty 6-month posttherapy (p = .04), as better baseline scores were associated with fewer residual symptoms. CONCLUSIONS Therapy with a speech-language pathologist for EILO allowed for more frequent physical activity following therapy completion and decreased dyspnea symptoms 6-month posttherapy. Therapy was associated with a decrease in inhaler use. PedsQL scores indicated mildly poor health-related quality of life even after EILO symptoms improved. Findings support therapy as an effective treatment for EILO in teenage athletes and suggest that dyspnea symptoms may continue to improve following discharge as patients continue using therapy techniques.
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Affiliation(s)
- Robert Brinton Fujiki
- Department of Surgery, University of Wisconsin-Madison
- Speech and Audiology Clinics, UW Health, Madison, WI
| | | | - Maia Braden
- Department of Communication Sciences and Disorders, University of Wisconsin-Madison
| | - Susan L Thibeault
- Department of Surgery, University of Wisconsin-Madison
- Department of Communication Sciences and Disorders, University of Wisconsin-Madison
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14
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Wells C, Makariou I, Barker N, Thevasagayam R, Sonnappa S. Exercise induced laryngeal obstruction (EILO) in children and young people: Approaches to assessment and management. Paediatr Respir Rev 2023:S1526-0542(23)00018-0. [PMID: 37210300 DOI: 10.1016/j.prrv.2023.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 05/22/2023]
Abstract
Exercise Induced Laryngeal Obstruction (EILO) is characterised by breathlessness, cough and/or noisy breathing particularly during high intensity exercise. EILO is a subcategory of inducible laryngeal obstruction where exercise is the trigger that provokes inappropriate transient glottic or supraglottic narrowing. It is a common condition affecting 5.7-7.5% of the general population and is a key differential diagnosis for young athletes presenting with exercise related dyspnoea where prevalence rates go as high as 34%. Although the condition has been recognised for a long time, little attention, and awareness of the condition results in many young people dropping out of sporting participation due to troublesome symptoms. With evolving understanding of the condition, diagnostic tests and interventions, this review looks to present the current available evidence and best practice when managing young people with EILO.
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Affiliation(s)
- Charlotte Wells
- Department of Respiratory Paediatrics, The Royal Brompton Hospital Part of Guy's and ST Thomas's NHS Foundation Trust, London, UK; University of East Anglia, Health Sciences, Norwich Research Park, Norwich, UK
| | - Ioannis Makariou
- Department of Respiratory Paediatrics, The Royal Brompton Hospital Part of Guy's and ST Thomas's NHS Foundation Trust, London, UK
| | - Nicki Barker
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Ravi Thevasagayam
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Samatha Sonnappa
- Department of Respiratory Paediatrics, The Royal Brompton Hospital Part of Guy's and ST Thomas's NHS Foundation Trust, London, UK.
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15
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Baek J, Jee DL, Choi YS, Kim SW, Choi EK. Paradoxical vocal fold motion masquerading as post-anesthetic respiratory distress: A case report. World J Clin Cases 2023; 11:2349-2354. [PMID: 37122517 PMCID: PMC10131007 DOI: 10.12998/wjcc.v11.i10.2349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/18/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Functional vocal cord disorders can be a differential diagnosis for postoperative upper airway obstruction requiring urgent intervention. However, this may be unfamiliar to anesthesiologists who would favor inappropriate airway intervention and increased morbidity. CASE SUMMARY A 61-year-old woman underwent cervical laminectomy, followed by laparoscopic cholecystectomy 10 mo later. Despite adequate reversal of neuromuscular blockade, the patient experienced repetitive respiratory difficulty with inspiratory stridor after extubation. After the second operation, the patient was diagnosed with paradoxical vocal fold motion (PVFM) by an otolaryngologist based on the clinical features and fiberoptic bronchoscopy results, and the patient was successfully treated. CONCLUSION PVFM should be considered a differential diagnosis if a patient presents with stridor after general anesthesia.
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Affiliation(s)
- Jongyoon Baek
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Dae-Lim Jee
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Yoon Seok Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Sang Woo Kim
- Department of Neurosurgery, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Eun Kyung Choi
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
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16
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Kumaresan T, Thomas M, Uppal PA, Setzen S, Brar S, Yalamanchili A, Panse D, Rodriguez RC, Suarez B, Kayajian D, Mortensen M. Predictors of voice therapy efficacy in vocal cord dysfunction at a tertiary care center. Am J Otolaryngol 2023; 44:103882. [PMID: 37031521 DOI: 10.1016/j.amjoto.2023.103882] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVE Vocal cord dysfunction is inappropriate adduction of vocal cords during inspiration that causes dyspnea and is commonly mistaken for exercise-induced asthma. To improve diagnostic accuracy, this study aims to identify demographics associated with vocal cord dysfunction and to determine their impact on the efficacy of voice therapy in improving vocal cord function. STUDY DESIGN Retrospective chart review. SETTING Single tertiary care institution between January 2015 and December 2021. METHODS 184 patients who underwent voice therapy for vocal cord dysfunction were included. The primary outcome was patient self-reported percent improvement of symptoms. The secondary outcome was number of voice therapy treatments. RESULTS The mean duration of symptoms was 2 ± 3 years. The mean number of voice therapy treatments was 2.2 ± 1.5. Of the 107 (58.2 %) patients with documented perceived breathing improvement percentages recorded, the mean maximal percent improvement was 72.5 ± 21.5 %. Mean maximal percent improvement of symptoms increased with each voice therapy treatment (p = 0.01). This association remained significant when controlling for comorbid conditions such as allergic rhinitis with postnasal drip, anxiety, asthma, and gastroesophageal reflux disease in multivariate analysis (p = 0.005). Patients with asthma had significantly higher maximum percent breathing improvement compared to those without asthma (p = 0.026). Similarly, patients who played sports had significantly higher maximum percent breathing improvement compared to those who did not (p = 0.022). CONCLUSION Patient perceived breathing improvement with voice therapy is higher among those with concomitant asthma and those who play sports. Voice therapy is a safe and effective first line treatment of vocal cord dysfunction even when controlling for comorbid conditions.
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Affiliation(s)
| | - Melissa Thomas
- Albany Medical College, Albany, NY, United States of America
| | - Priya A Uppal
- Albany Medical College, Albany, NY, United States of America
| | - Sean Setzen
- Albany Medical College, Albany, NY, United States of America
| | - Simran Brar
- Albany Medical College, Albany, NY, United States of America
| | | | - Drishti Panse
- Albany Medical College, Albany, NY, United States of America
| | - Rafael Cardona Rodriguez
- Department of Otolaryngology and Head-Neck Surgery, Albany Medical Center, Albany, NY, United States of America
| | - Bethzaida Suarez
- Department of Otolaryngology and Head-Neck Surgery, Albany Medical Center, Albany, NY, United States of America
| | - Daniel Kayajian
- Department of Otolaryngology and Head-Neck Surgery, Albany Medical Center, Albany, NY, United States of America
| | - Melissa Mortensen
- Department of Otolaryngology and Head-Neck Surgery, Albany Medical Center, Albany, NY, United States of America.
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17
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Novaleski CK, Doty RL, Nolden AA, Wise PM, Mainland JD, Dalton PH. Examining the Influence of Chemosensation on Laryngeal Health and Disorders. J Voice 2023; 37:234-244. [PMID: 33455853 PMCID: PMC8277875 DOI: 10.1016/j.jvoice.2020.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Abstract
Inhaled airborne stimuli are associated with laryngeal disorders affecting respiration. Clinically, several themes emerged from the literature that point to specific gaps in the understanding and management of these disorders. There is wide variation in the types of airborne stimuli that trigger symptoms, lack of standardization in provocation challenge testing using airborne stimuli, and vague reporting of laryngeal symptoms. Scientifically, evidence exists outside the field of voice science that could prove useful to implement among patients with impaired laryngeal-respiration. To expand this area of expertise, here we provide a thematic overview of relevant evidence and methodological tools from the discipline of chemosensory sciences. This review provides distinctions across the three chemosensory systems of olfaction, trigeminal chemesthesis, and gustation, guidance on selecting and delivering common chemosensory stimuli for clinical testing, and methods of quantifying sensory experiences using principles of human psychophysics. Investigating the science of chemosensation reveals that laryngeal responses to inhaled airborne stimuli have explanations involving physiological mechanisms as well as higher cognitive processing. Fortunately, these findings are consistent with current pharmacological and nonpharmacological interventions for impaired laryngeal-respiration. Based on the close relationships among inhaled airborne stimuli, respiration, and laryngeal function, we propose that new perspectives from chemosensory sciences offer opportunities to improve patient care and target areas of future research.
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Affiliation(s)
- Carolyn K Novaleski
- Monell Chemical Senses Center, Philadelphia, Pennsylvania; Department of Communicative Sciences and Disorders, Michigan State University, East Lansing, Michigan; Department of Neurology, Mayo Clinic, Rochester, Minnesota.
| | - Richard L Doty
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alissa A Nolden
- Department of Food Science, University of Massachusetts-Amherst, Amherst, Massachusetts
| | - Paul M Wise
- Monell Chemical Senses Center, Philadelphia, Pennsylvania
| | - Joel D Mainland
- Monell Chemical Senses Center, Philadelphia, Pennsylvania; Department of Neuroscience, University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Koh J, Phyland D, Baxter M, Leong P, Bardin PG. Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics. Expert Rev Respir Med 2023; 17:429-445. [PMID: 37194252 DOI: 10.1080/17476348.2023.2215434] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based. AREAS COVERED A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure. EXPERT OPINION Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.
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Affiliation(s)
- Joo Koh
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Debra Phyland
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Malcolm Baxter
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Paul Leong
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
| | - Philip G Bardin
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
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19
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Espindula BF, Lima E, Rodrigues AJ, Cukier A. Endoscopic aspects and associated factors in paradoxical vocal fold movement. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2022; 73:292-298. [PMID: 36113920 DOI: 10.1016/j.otoeng.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/29/2021] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Paradoxical vocal fold movement (PVFM) is a respiratory disorder related to inadequate movement of vocal folds during inspiration or expiration. Its epidemiology and pathogenesis are unknown. The present study describes the standardization of the examination performed in our service and the main endoscopic changes found, evaluating the prevalence of PVFM in patients with suggestive symptoms and describing the association of PVFM with asthma and other diseases. MATERIALS AND METHODS Retrospective observational study of a series of cases over a 13-year period - adult patients referred for outpatient bronchoscopy due to suspected PVFM. RESULTS We analyzed 1131 laryngoscopies performed on patients referred for suspicion of PVFM from May 2006 to June 2019. Of these, 368 cases were excluded from the study. A total of 255 patients (33%) had a confirmed diagnosis of PVFM, 224 women (88%). The most frequent comorbidities found were asthma (62%), rhinitis (45%), gastro-oesophageal reflux disease (45%), obesity (24%), and psychiatric disorders (19%). Among the endoscopic findings concomitant with the diagnosis of PVDM, we highlight posterior laryngitis (71%), diseases of the nasal septum (18%), nasal polyps (7%). DISCUSSION Female sex is more affected. There are several associations with other diseases, the main one being asthma, followed by rhinitis and psychiatric disorders. Obesity appears as a comorbidity in 24% of patients, as does sleep apnoea in 13%. Posterior laryngitis was the most common endoscopic finding. PVFM is an underdiagnosed disease, little known as it is a rare entity that still needs prospective studies. Exam standardization is important.
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Affiliation(s)
- Bianca Fidelix Espindula
- Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Evelise Lima
- Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
| | - Ascédio Jose Rodrigues
- Respiratory Endoscopy Service, Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Alberto Cukier
- Pulmonary Division, Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
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20
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Solomon NP, Pham A, Gallena S, Johnson AT, Vossoughi J, Faroqi-Shah Y. Resting Respiratory Resistance in Female Teenage Athletes With and Without Exercise-Induced Laryngeal Obstruction. J Voice 2022; 36:734.e1-734.e6. [PMID: 32988702 PMCID: PMC7990743 DOI: 10.1016/j.jvoice.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Exercise-induced laryngeal obstruction (EILO) occurs with paradoxical vocal fold motion or supraglottic collapse during moderate to vigorous exercise. Previously, Gallena et al (2015) reported lower-than-normal inspiratory (Ri) and expiratory (Re) resistances during resting tidal breathing (RTB) in female teenage athletes with EILO. This study aimed to replicate that unexpected result. METHOD The Airflow Perturbation Device measured Ri and Re during three 1-minute trials of RTB in 16 teenage female athletes with EILO and 16 sex-, age-, and height-matched controls. Multiple linear regression examined group, age, height, and weight as predictors of Ri and Re. RESULTS Ri and Re tended to be lower in the EILO group than the control group [Ri: F(1,30) = 3.58, P = 0.068, d = 0.686; Re: F(1,30) = 3.28, P = 0.080, d = 0.640], but there was no statistically significant difference in the overall effect [F(2,29) = 1.75, P = 0.192]. After one outlier for Re from the EILO group and her matched control were removed, the overall difference was statistically significant, F(2,27) = 3.38, P = 0.049, with Re primarily contributing to the difference [Ri: F(1,28) = 3.66, P = 0.066, d = 0.719; Re: F(1,28) = 5.69, P = 0.024, d = 0.899]. CONCLUSION These results did not replicate the robust differences found previously between Ri and Re during RTB in teenage girls with and without EILO, but the results trended in the same direction and met criterion for statistical significance once an outlier was removed from analysis. Overall, the observation that resting respiratory resistances were lower in most teenage girls with EILO suggests that reduced tone of the laryngeal and/or lower airways may predispose young athletes to EILO.
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Affiliation(s)
- Nancy Pearl Solomon
- Walter Reed National Military Medical Center, Bethesda, Maryland; University of Maryland, College Park, Maryland.
| | - Andrea Pham
- University of Maryland, College Park, Maryland; Montgomery County Public Schools, Rockville, Maryland
| | | | | | - Jafar Vossoughi
- Engineering & Scientific Research Associates, Brookeville, Maryland
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21
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Espindula BF, Lima E, Rodrigues AJ, Cukier A. Endoscopic aspects and associated factors in paradoxical vocal fold movement. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2022. [DOI: 10.1016/j.otorri.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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22
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Fujiki RB, Fujiki AE, Thibeault S. Factors impacting therapy duration in children and adolescents with Paradoxical Vocal Fold Movement (PVFM). Int J Pediatr Otorhinolaryngol 2022; 158:111182. [PMID: 35594796 PMCID: PMC11816249 DOI: 10.1016/j.ijporl.2022.111182] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Paradoxical Vocal Fold Movement (PVFM) may cause airway restriction and resulting dyspnea in the pediatric population. Therapy with a speech-language pathologist (SLP) is the primary treatment for children and adolescents diagnosed with Paradoxical Vocal Fold Movement (PVFM). This study examined treatment duration and factors predicting number of therapy sessions required. METHODS Data were drawn from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. One hundred and twelve children and adolescents were included in this study. Participants were diagnosed with PVFM, followed for therapy with a SLP, and were subsequently discharged from therapy with successful outcomes. Extracted data included number of therapy sessions, PVFM symptoms, patient demographics, medical history, and comorbid diagnoses. Regression was used to determine factors predicting therapy duration. RESULTS Patients completed an average of 3.4 therapy sessions before discharge. Comorbid behavioral health diagnosis (β = 1.96, t = 3.83, p < .01) and a history of upper airway surgeries (β = 1.26, t = 2.615, p = .01) were significant predictors of the number of therapy sessions required before discharge; both factors significantly increased therapy duration. Age, symptom trigger-type, reflux symptoms, and dysphonia did not predict therapy duration. Overall, our regression model accounted for 42% of the variance in number of sessions required (r2 = 0.42). CONCLUSIONS On average, 3.4 sessions of therapy with an SLP resolved PVFM symptoms. Children with a behavioral health diagnosis required an average of 5.45 sessions and those with a history of upper airway surgery an average of 4.3 sessions. Future work should examine the relationship between behavioral health care and PVFM treatment, as well as how PVFM treatment efficiency can be maximized. LEVEL OF EVIDENCE: 3
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Affiliation(s)
| | - Amanda Edith Fujiki
- Department of Psychiatry, Child and Adolescent Division, University of Utah School of Medicine, United States
| | - Susan Thibeault
- Department of Surgery, University of Wisconsin, Madison, United States.
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Poggiali E, Di Trapani G, Agosti A, Caiazza C, Manicardi A, Zanzani C, Vollaro S, Vercelli A. A case of vocal cord dysfunction in the emergency department. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We describe the case of a 78-year-old woman admitted to our emergency department for an acute onset of severe dyspnoea with inspiratory wheezing-like sounds. She denied fever, cough, voice change and pain. She referred a similar but less severe episode occurred spontaneously one year before, with complete resolution in few minutes without sequelae. On examination upper airway obstruction was firstly excluded. She was initially treated as having asthma, without response. Parenteral high dose corticosteroids and antihistamines provided no benefit. Point-of-care-ultrasound resulted normal. Flexible laryngoscopy during the episode showed paradoxical vocal cord movement with adduction during both inspiration and expiration. This demonstrated that her dyspnoea was from Vocal Cord Dysfunction (VCD). VCD completely solved after administration of intravenous benzodiazepines.
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Die induzierbare laryngeale Obstruktion (ILO) – Ursachen, klinische Präsentation, Diagnostik und Therapie. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01159-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
ZusammenfassungWiederholt episodenhaft auftretende Atemnot ist im Kindes- und Jugendalter ein häufiges Symptom. Neben anstrengungsinduzierter Bronchialobstruktion im Rahmen eines Asthma bronchiale ist eine funktionelle Genese eine sehr häufige Differenzialdiagnose. Dennoch wird diese Diagnose häufig nicht oder mit langer Latenz gestellt. Unter dem Oberbegriff „ILO“ („inducible laryngeal obstruction“) werden sowohl funktionelle supraglottische Obstruktionen durch Kollaps der Knorpelstrukturen als auch Dysfunktionen auf Glottisebene wie „vocal cord dysfunction“ (VCD) subsumiert. Körperliche Anstrengung ist ein häufiger Auslöser; es werden jedoch auch Beschwerdebilder ohne Anstrengungsbezug beobachtet. Es wird der Erkenntnisstand zur Pathophysiologie referiert und die klinische Präsentation beschrieben. Ein wesentlicher Fokus des Artikels liegt im Folgenden auf der Darstellung eines sinnvollen und Ressourcen-orientierten diagnostischen Vorgehens. Der CLE-Test („continuous laryngoscopy exercise test“) als Provokationsmethode unter Wach-Videolaryngoskopie ist der Goldstandard, jedoch wird diese Diagnostik im deutschsprachigen Raum nicht flächendeckend vorgehalten. Dieses Positionspapier stellt daher die diagnostische Wertigkeit verschiedener anderer Diagnostik-Algorithmen und anamnestischer Informationen heraus. Ein weiterer Schwerpunkt des Papiers besteht in der detaillierten Vorstellung geeigneter atemphysiotherapeutischer Interventionen.
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Lunga T, Thibeault SL, Francis DO. Economic Burden Associated With Management of Paradoxical Vocal Fold Motion Disorder. Laryngoscope 2021; 132:142-147. [PMID: 34272886 DOI: 10.1002/lary.29754] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/11/2021] [Accepted: 07/06/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Paradoxical vocal fold movement (PVFM) is often misdiagnosed as asthma and tends to have a prolonged time to diagnosis. Study aims were to estimate the time from dyspnea onset to PVFM diagnosis, to estimate associated pre- and postdiagnosis direct and indirect healthcare cost, and to compare the cost of postdiagnosis care among patients who did and did not undergo standard-of-care speech therapy. METHODS Patients diagnosed with PVFM were identified retrospectively. Time from dyspnea symptom onset to diagnosis was measured. Direct costs consisting of office visits, procedures, and prescribed pharmaceuticals before and after diagnosis were calculated. Indirect costs associated with lost wages related to healthcare were also estimated. Costs for patients who initiated versus did not initiate speech therapy and who had successful versus unsuccessful therapy were compared. RESULTS Among 110 patients, median time from dyspnea onset to PVFM diagnosis was 33 months (interquartile range [IQR] 5-60). Direct and indirect prediagnosis median costs were $8,625 (IQR $1,687-$35,812) and $736 (IQR $421-$1,579) while first year following dyspnea symptom onset median direct and indirect costs were $1,706 (IQR $427-$7,118) and $315 (IQR $131-$631). Median direct and indirect costs of care in the postdiagnosis year were $2,062 (IQR $760-$11,496) and $841 (IQR $631-$1,261). Pharmaceuticals were predominant cost drivers in all time periods. Of those who completed speech therapy, 85% had breathing symptom improvement while incurring significant cost savings compared to those whose symptoms persisted. CONCLUSION Costs of care leading to diagnosis of PVFM are substantial. More efficient methods of identifying patients with PVFM are essential to reduce prolonged time to diagnosis and associated costs. LEVEL OF EVIDENCE N/A Laryngoscope, 2021.
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Affiliation(s)
- Tadeas Lunga
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Susan L Thibeault
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - David O Francis
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
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LeBlanc RA, Aalto D, Jeffery CC. Visual biofeedback for paradoxical vocal fold motion (PVFM). J Otolaryngol Head Neck Surg 2021; 50:13. [PMID: 33602342 PMCID: PMC7891140 DOI: 10.1186/s40463-021-00495-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/19/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives Paradoxical vocal fold motion (PVFM) is a common condition where the vocal folds inappropriately adduct during inspiration. This results in dyspnea and occasionally significant distress. The condition is thought to be primarily functional, with behavioural therapy considered mainstay in the non-acute setting. However, practice variations and limited access to speech language pathology (SLP) services can pose management challenges. We aimed to examine the efficacy of surgeon performed visual biofeedback as first-line treatment for PVFM. Study design Prospective, non-randomized, non-comparative clinical study. Methods Adult patients referred for possible PVFM and congruent laryngoscopy findings over a two-year period were included. Patients were excluded if they presented in acute distress, had alternate diagnosis to explain symptomology and/or coexisting untreated lower respiratory pathology. Patients underwent immediate surgeon-performed visual biofeedback on the same visit day. The primary outcome of interest was change in Dyspnea Index (DI) scores pre- and post-intervention 3 months follow-up. The secondary outcome measured was change in asthma medication use from baseline to follow-up. Results Of 34 patients presenting, 25 met inclusion criteria. Of these, 72% were female with an average age of 36.9 ± 14.1. Approximately 48% of patients had a diagnosis of well-controlled asthma at presentation and co-morbid psychiatric diagnoses were common (52%). Pre- and post-intervention analysis showed significant improvement in DI scores (p < 0.001) and reduction in bronchodilator use (p = 0.003). Conclusion This is a prospective study that evaluates the role of visual biofeedback in PVFM patients. Our data suggests that visual biofeedback effectively reduces short-term subjective symptoms and asthma medication use. Level of evidence 3 Graphical abstract ![]()
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Affiliation(s)
- Rachelle Alyce LeBlanc
- Division of Otolaryngology Head and Neck Surgery, Department of Surgery, University of Alberta, 1E4 Walter Mackenzie Centre, 8440-112 Street NW, Edmonton, Alberta, T6G 2B7, Canada
| | - Daniel Aalto
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Caroline C Jeffery
- Division of Otolaryngology Head and Neck Surgery, Department of Surgery, University of Alberta, 1E4 Walter Mackenzie Centre, 8440-112 Street NW, Edmonton, Alberta, T6G 2B7, Canada.
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Ivancic R, Matrka L, Wiet G, Puckett A, Haney J, deSilva B. Reduced Asthma Medication Use after Treatment of Pediatric Paradoxical Vocal Fold Motion Disorder. Laryngoscope 2020; 131:1639-1646. [PMID: 33274767 DOI: 10.1002/lary.29283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 10/20/2020] [Accepted: 11/17/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESES The primary objective of this study was to determine whether the diagnosis and treatment of pediatric Paradoxical Vocal Fold Motion Disorder (PVFMD) leads to decreased asthma medication use. Our secondary objective was to determine dyspnea outcomes following diagnosis and treatment for PVFMD. STUDY DESIGN Prospective observational study. METHODS Patients with newly diagnosed PVFMD between the ages of 11 and 17 were recruited at a single pediatric institution. A medication questionnaire and Dyspnea Index (DI) were completed at the initial visit, at the first return visit, and at greater than 6 months post-diagnosis and therapy. Laryngeal Control Therapy (LCT) consisted of teaching breathing techniques and identifying emotional, physical, and environmental contributing factors and strategies to reduce them. RESULTS Twenty-six patients were recruited to the study. There were 19/26 (73%) patients diagnosed with asthma prior to a diagnosis of PVFMD, and 26/26 (100%) patients were using an inhaler prior to the enrollment visit. Twenty-two (85%) patients completed follow-up questionnaires. Five patients participated in no therapy, seven patients in partial therapy, and 14 patients in full therapy. Significant reduction in asthma medication use was seen in the full therapy group (P < .05) and in those with exercise as their only trigger (P < .05). Furthermore, symptoms as scored by the DI decreased overall from 25.5 to 18.8 (P < .001). CONCLUSIONS Diagnosis and treatment of pediatric PVFMD leads to a decline in asthma medication use in those patients who participate in at least two LCT sessions and in those with exercise-induced PVFMD. LCT for pediatric PVFMD leads to a significant decrease in symptoms as measured by the DI. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1639-1646, 2021.
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Affiliation(s)
- Ryan Ivancic
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Laura Matrka
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Gregory Wiet
- Department of Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, U.S.A
| | - Amy Puckett
- Department of Speech Pathology, Nationwide Children's Hospital, Columbus, Ohio, U.S.A
| | - Jennifer Haney
- Department of Speech Pathology, Nationwide Children's Hospital, Columbus, Ohio, U.S.A
| | - Brad deSilva
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, U.S.A
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Hancox RJ, Morgan J, Dickson N, Connor J, Baxter JM. Rape, asthma and dysfunctional breathing. Eur Respir J 2020; 55:13993003.02455-2019. [PMID: 32184316 DOI: 10.1183/13993003.02455-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/23/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Robert J Hancox
- Dept of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jane Morgan
- Dept of Sexual Health, Waikato Hospital, Hamilton, New Zealand
| | - Nigel Dickson
- Dept of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jennie Connor
- Dept of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Joanne M Baxter
- Kōhatu - Centre for Hauora Māori, University of Otago, Dunedin, New Zealand
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Hull JH, Godbout K, Boulet LP. Exercise-Associated Dyspnea and Stridor: Thinking Beyond Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2202-2208. [PMID: 32061900 DOI: 10.1016/j.jaip.2020.01.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 12/26/2022]
Abstract
Breathlessness during sport can be caused by various cardiorespiratory conditions, but when associated with stridor, usually arises from an upper airway etiology. The term exercise-induced laryngeal obstruction (EILO) is now used to describe the phenomenon of transient glottic closure occurring in association with physical activity. Exercise-related laryngeal closure is most commonly encountered in athletic individuals and likely affects between 5% and 7% of all young adults and adolescents. The diagnosis of EILO is not always straightforward because features can overlap with exercise-induced asthma/exercise-induced bronchoconstriction. EILO can therefore remain misdiagnosed for years, and most patients receive inappropriate asthma therapy. In contrast with asthma, EILO symptoms are usually most prominent at maximal exercise intensity and resolve quickly on exercise cessation. It is important to recognize that EILO and asthma can coexist in a proportion of athletes. The criterion standard test for diagnosing EILO is continuous laryngoscopy during exercise testing, although eucapnic voluntary hyperpnea testing has also been used. Various surgical or pharmacological interventions can be used to treat EILO, but first-line treatment is breathing technique work. Further research is needed to establish the optimal treatment algorithm, and more work is needed to increase awareness of this important clinical entity.
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Affiliation(s)
- James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Krystelle Godbout
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada
| | - Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada.
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Barker N, Thevasagayam R, Ugonna K, Kirkby J. Pediatric Dysfunctional Breathing: Proposed Components, Mechanisms, Diagnosis, and Management. Front Pediatr 2020; 8:379. [PMID: 32766182 PMCID: PMC7378385 DOI: 10.3389/fped.2020.00379] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
Dysfunctional breathing (DB) is an overarching term describing deviations in the normal biomechanical patterns of breathing which have a significant impact on quality of life, performance and functioning. Whilst it occurs in both children and adults, this article focuses specifically on children. DB can be viewed as having two components; breathing pattern disorder (BPD) and inducible laryngeal obstruction (ILO). They can be considered in isolation, however, are intricately related and often co-exist. When both are suspected, we propose both BPD and ILO be investigated within an all-encompassing multi-disciplinary dysfunctional breathing clinic. The MDT clinic can diagnose DB through expert history taking and a choice of appropriate tests/examinations which may include spirometry, breathing pattern analysis, exercise testing and laryngoscopic examination. Use of the proposed algorithm presented in this article will aid decision making regarding choosing the most appropriate tests and understanding the diagnostic implications of these tests. The most common symptoms of DB are shortness of breath and chest discomfort, often during exercise. Patients with DB typically present with normal spirometry and an altered breathing pattern at rest which is amplified during exercise. In pediatric ILO, abnormalities of the upper airway such as cobblestoning are commonly seen followed by abnormal activity of the upper airway structures provoked by exercise. This may be associated with a varying degree of stridor. The symptoms, however, are often misdiagnosed as asthma and the picture can be further complicated by the common co-presentation of DB and asthma. Associated conditions such as asthma, extra-esophageal reflux, rhinitis, and allergy must be treated appropriately and well controlled before any directed therapy for DB can be started if therapy is to be successful. DB in pediatrics is commonly treated with a course of non-pharmaceutical therapy. The therapy is provided by an experienced physiotherapist, speech and language therapist or psychologist depending on the dominant features of the DB presentation (i.e., BPD or ILO in combination or in isolation) and some patients will benefit from input from more than one of these disciplines. An individualized treatment program based on expert assessment and personalized goals will result in a return to normal function with reoccurrence being rare.
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Affiliation(s)
- Nicki Barker
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Ravi Thevasagayam
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Kelechi Ugonna
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Jane Kirkby
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
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32
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Shembel AC, Hartnick CJ, Bunting G, Ballif C, Shaiman S, de Guzman V, Abbott KV. Perceptual Clinical Features in Exercise-Induced Laryngeal Obstruction (EILO): Toward Improved Diagnostic Approaches. J Voice 2019; 33:880-893. [DOI: 10.1016/j.jvoice.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/17/2018] [Indexed: 10/28/2022]
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Petrov AA. Vocal Cord Dysfunction: The Spectrum Across the Ages. Immunol Allergy Clin North Am 2019; 39:547-560. [PMID: 31563188 DOI: 10.1016/j.iac.2019.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Vocal cord dysfunction (VCD) is an upper airway disorder characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms. Although the origin of VCD symptoms is in the upper airway, it is frequently misdiagnosed as asthma resulting in significant morbidity. VCD can coexist with asthma or mimic allergic conditions affecting the upper airway. VCD may be difficult to diagnose, because patients are intermittently symptomatic and VCD awareness in the medical community is underappreciated. Once VCD is diagnosed and treated, most patients report significant improvement in their symptoms as well as a decrease in asthma medication use.
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Affiliation(s)
- Andrej A Petrov
- Section of Allergy, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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34
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Susanto C. Sudden onset dyspnoea and recurrent stridor. Med J Aust 2019; 208:159-160. [PMID: 29490217 DOI: 10.5694/mja16.01397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 02/22/2017] [Indexed: 11/17/2022]
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35
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Rendo M, Sjulin TJ, Morris MJ, Burguete S. Upper airway wheezing: Inducible laryngeal obstruction vs. excessive dynamic airway collapse. Respir Med Case Rep 2019; 27:100827. [PMID: 30989047 PMCID: PMC6446124 DOI: 10.1016/j.rmcr.2019.100827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 12/02/2022] Open
Abstract
There are multiple causes of dyspnea upon exertion in young, healthy patients to primarily include asthma and exercise-induced bronchospasm. Excessive dynamic airway collapse (EDAC) describes focal collapse of the trachea or main bronchi with maintained structural integrity of the cartilaginous rings. It is commonly associated with pulmonary disorders like bronchiectasis, chronic obstructive pulmonary disease and asthma. It is believed to result secondary to airway obstruction in these conditions. While uncommon in young, healthy adults, it has recently been found as a cause of dyspnea in this population. Inducible laryngeal obstruction (ILO) is an umbrella term that describes an induced, intermittent upper airway impediment. While ILO is found in 10% of young patients with exertional dyspnea, it is primarily inspiratory in nature due to paradoxical closure of the glottis or supraglottis. This report highlights the presentation of a United States Army soldier who after a deployment was given a diagnosis of asthma, later found to have ILO and was subsequently diagnosed with concurrent EDAC. We follow up with a literature review and discussion of symptomatology, diagnosis, exercise bronchoscopy, and treatment modalities for both EDAC and ILO.
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Affiliation(s)
- Matthew Rendo
- San Antonio Military Medical Center, Internal Medicine, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6160, USA
| | - Tyson J Sjulin
- San Antonio Military Medical Center, Pulmonary/Critical Care, USA
| | - Michael J Morris
- San Antonio Military Medical Center, Pulmonary/Critical Care, USA
| | - Sergio Burguete
- University of Texas Health Science Center at San Antonio, Pulmonary/Critical Care, USA
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36
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Baxter M, Ruane L, Phyland D, Leahy E, Heke E, Lau KK, Low K, Hamza K, MacDonald M, Bardin PG. Multidisciplinary team clinic for vocal cord dysfunction directs therapy and significantly reduces healthcare utilization. Respirology 2019; 24:758-764. [PMID: 30884033 DOI: 10.1111/resp.13520] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/30/2018] [Accepted: 02/18/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Multidisciplinary team (MDT) clinics use an integrated approach to individualize care of complex medical conditions. Vocal cord dysfunction (VCD) is a challenging condition that is likely to benefit from MDT clinics but this has not been researched. METHODS A prospective observational cohort study of a novel VCD MDT clinic was conducted in patients with suspected VCD. Relevant questionnaires, medical history, physical examination, spirometry, dynamic computerized tomography (CT) larynx and laryngoscopy were utilized and patients were allocated to treatment pathways depending on putative diagnosis. Speech pathology intervention with laryngeal retraining (LR) was offered and if LR therapy failed botulinum toxin injection was offered. Primary outcome was reductions in healthcare utilization. RESULTS Overall, 80 consecutive patients were included in analyses. A definitive diagnosis of VCD was made in 56 of 80 (70%) patients. After LR (n = 35), emergency department (ED)/hospital admissions declined significantly in the subsequent 12 months (P = 0.001). General practice visits also reduced (P < 0.001). Botulinum toxin injections were administered in 21 patients unresponsive to LR therapy and both general practice and ED/hospital visits declined (P < 0.001 and P = 0.01, respectively) after injection. CONCLUSION A multidisciplinary approach to VCD confers benefit and can be used to allocate appropriate management leading to a reduction in healthcare utilization.
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Affiliation(s)
- Malcolm Baxter
- Department Otolaryngology, Head and Neck Surgery, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
| | - Debra Phyland
- Department Otolaryngology, Head and Neck Surgery, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Elizabeth Leahy
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia
| | - Emily Heke
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia
| | - Kenneth K Lau
- Diagnostic Imaging, Monash University and Monash Health, Melbourne, VIC, Australia
| | - Kathy Low
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
| | - Kais Hamza
- Department of Mathematical Sciences, Monash University, Melbourne, VIC, Australia
| | - Martin MacDonald
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
| | - Philip G Bardin
- Monash Lung and Sleep, Monash University and Hospital, Melbourne, Victoria, Australia.,Hudson Institute, Melbourne, VIC, Australia
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37
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Tobey ABJ, Maguire RC. Dynamic tonsillar prolapse masquerading as paradoxical vocal fold movement dysfunction. Int J Pediatr Otorhinolaryngol 2019; 118:68-72. [PMID: 30583196 DOI: 10.1016/j.ijporl.2018.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/12/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Paradoxical vocal fold movement dysfunction (PVFMD) is a disorder in which the vocal folds involuntarily adduct during inspiration resulting in stridor, cough, dysphonia and dyspnea. Diagnosis of PVFMD is difficult given the episodic nature of the disorder and the often-normal laryngeal exam in between episodes. Moreover, additional sources of obstruction have been identified as sources of Periodic Occurrence of Laryngeal Obstruction (POLO). Treatments can vary with site of obstruction. OBJECTIVE To evaluate pediatric patients presenting to a Vocal Fold Dysfunction Center for evaluation of exertional, inspiratory, harsh breath sounds and dyspnea suggestive of PVFMD whom were found to have a dynamic obstruction of the upper airway due to adenotonsillar hypertrophy and prolapse. METHODS Retrospective chart review of patients diagnosed with exertional dynamic tonsillar prolapse whom have undergone adenotonsillectomy. Clinical characteristics, spirometry, exam findings and response to adenotonsillectomy were recorded. RESULTS Seven patients with exercise induced dyspnea and respiratory distress with whom underwent exercise spirometry then subsequent adenotonsillectomy were identified. Symptomatic co-morbidities were common and included: rhinitis (43%), reflux (29%), sleep disordered breathing (29%), asthma (14%), obesity (14%), prematurity (14%) and anxiety/post-traumatic stress disorder (PTSD) (14%). Preoperative use of bronchodilators or reflux medications was common. All patients were noted to have >50% oropharyngeal obstruction secondary to tonsillar hypertrophy and dynamic lateral pharyngeal collapse or tonsillar prolapse with inspiration. No exercise induced paradoxical vocal fold dysfunction was identified. All baseline and most exertion FVC, FEV1, FEV1/FVC and FEF 25-75% were normal. Four patients had flow volume loops suggestive of obstruction. All patients had symptomatic improvement after adenotonsillectomy. CONCLUSIONS Dynamic tonsillar prolapse can result in subjective exertional dyspnea and objective upper airway resistance mimicking PVFMD and treatment with adenotonsillectomy can greatly reduce symptoms.
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Affiliation(s)
- Allison B J Tobey
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, USA.
| | - Raymond C Maguire
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, USA
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Pasternak K, Thibeault SL. Factors Affecting Initiation of Voice Therapy for Paradoxical Vocal Fold Motion Disorder. J Voice 2019; 34:559-566. [PMID: 30660338 DOI: 10.1016/j.jvoice.2018.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate patient-level predictors of initiation of voice therapy for paradoxical vocal fold motion disorder (PVFM). STUDY DESIGN Prospective outcomes database study. METHODS Patients consented to the University of Wisconsin Voice and Swallow Clinics Outcomes Database between March 2010 and November 2016 who were diagnosed with PVFM and recommended for voice therapy were eligible. Patients who attended at least one voice therapy session were considered to have initiated therapy. Analyzed variables included age, gender, distance to the clinic, insurance status, socioeconomic factors, comorbidity score, spirometry results, presence of asthma and/or dysphonia diagnoses, length of evaluation and evaluation model, and patient scores on the Voice Handicap Index and Generalized Anxiety Disorder 7-item scale. RESULTS One-hundred seventy-eight patients met inclusion criteria. Of these, 118 initiated voice therapy as recommended (66.29%). The majority of patients were female (n = 127; 71.35%). Age was the only factor significantly associated with therapy initiation in both univariate (P = 0.0359) and multivariable (P = 0.0295) analyses, with patients aged 30-39 least likely to attend compared with other age groups. Multivariable analysis also showed that patients evaluated by a speech-language pathologist alone were an estimated three times as likely to initiate therapy compared to patients evaluated by speech-language pathologist and otolaryngologist (ENT) together (P = 0.0407). Other variables were not statistically significant for prediction of therapy initiation. CONCLUSIONS This study suggests that age group and evaluation model are associated with initiation of voice therapy for PVFM. Further study is needed to investigate social-cognitive and quality-of-life factors in predicting therapy initiation.
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Affiliation(s)
- Kevin Pasternak
- Voice and Swallow Clinics, University Hospital, Madison, Wisconsin.
| | - Susan L Thibeault
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
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Wenzel M. Gasping for a Diagnosis: Pediatric Vocal Cord Dysfunction. J Pediatr Health Care 2019; 33:5-13. [PMID: 29657076 DOI: 10.1016/j.pedhc.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 03/11/2018] [Indexed: 02/05/2023]
Abstract
Vocal cord dysfunction is an obstruction of the upper airway, primarily on inspiration, due to the paradoxical adduction of the vocal cords. Vocal cord dysfunction continues to be underdiagnosed as its own entity. The lack of diagnosis can be attributed to the overlap of symptoms between asthma and exercise-induced bronchospasm. It is possible for patients diagnosed with asthma and/or exercise-induced bronchospasm to have underlying vocal cord dysfunction, which needs to be considered when prescribing asthma medications. This article will review the history of vocal cord dysfunction, the differential diagnosis, diagnostic testing, and the role of the nurse practitioner in caring for these patients.
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Vocal cord dysfunction and bronchial asthma. КЛИНИЧЕСКАЯ ПРАКТИКА 2018. [DOI: 10.17816/clinpract9474-79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The syndromology of dysfunction of the vocal cords varies widely from the absence of symptoms to mild shortness of breath to acute respiratory disfunction, which can mimic an asthma attack. The treatment of vocal dysfunction and bronchial asthma is different. An early fold diagnosis of vocal dysfunction can prevent improper treatment and, therefore, minimize the rising costs of health care.
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Shaffer M, Litts JK, Nauman E, Haines J. Speech-Language Pathology as a Primary Treatment for Exercise-Induced Laryngeal Obstruction. Immunol Allergy Clin North Am 2018; 38:293-302. [DOI: 10.1016/j.iac.2018.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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O'Connell Ferster AP, Shokri T, Carr M. Diagnosis and treatment of paradoxical vocal fold motion in infants. Int J Pediatr Otorhinolaryngol 2018; 107:6-9. [PMID: 29501313 DOI: 10.1016/j.ijporl.2018.01.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 11/30/2022]
Abstract
IMPORTANCE Paradoxical vocal fold motion (PVFM) is a disorder often misdiagnosed in children presenting with shortness of breath and stridor. In infants, little is known about the clinical course and best approach for treatment of PVFM. This retrospective study assesses the approach to treatment and outcomes for infants with PVFM. OBJECTIVE To investigate the clinical course of paradoxical vocal fold motion (PVFM) in infants. DESIGN Retrospective review. SETTING Tertiary academic medical center. PARTICIPANTS Patients less than 2 years of age diagnosed with PVFM were identified and included in the study. MAIN OUTCOMES AND MEASURES History, physical exam findings, and clinical course of treatment for patients less than 2 years old with PVFM were reviewed. Findings including those on flexible fiberoptic laryngoscopy (FFL) and subjective assessment by parents and clinicians were compiled for review. RESULTS Seven infants were diagnosed with PVFM. All patients were full term at birth, and average age at diagnosis was 7 months. All patients initially presented with inspiratory stridor, and two patients had stertor. Two of seven patients also had a history of reactive airway disease and one with laryngomalacia. Five had a history of reflux. Two of seven patients had weight percentiles at diagnosis lower than the 25th percentile, while the remainder were between 37th and 75th percentiles. Initial voice evaluation revealed stridor in all patients, as well as finding of PVFM on FFL. All patients were started on anti-reflux medication. Average time to resolution of PVFM was 5.9 months after treatment. CONCLUSIONS PVFM can be challenging to diagnose in the infant population. PVFM resolves uneventfully with reflux treatment, however, it is unknown whether reflux treatment is essential or if PVFM would spontaneously resolve. The rarity of infantile PVFM mandates formal evaluation and monitoring by a pediatric otolaryngologist.
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Affiliation(s)
- Ashley P O'Connell Ferster
- Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, United States.
| | - Tom Shokri
- Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, United States
| | - Michele Carr
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, United States
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Soares M, Rodrigues A, Morais-Almeida M. Inducible Laryngeal Obstruction in the Paediatric Population – Review of the Literature and Current Understanding. ACTA ACUST UNITED AC 2018. [DOI: 10.17925/erpd.2018.4.1.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Inducible laryngeal obstruction (ILO) is a complex entity and its exact mechanisms are still unclear. It is characterised by transient and reversible narrowing of the larynx in response to external triggers, resulting in symptoms such as cough, dyspnoea and noisy breathing. The prevalence of this condition in adult or paediatric populations is uncertain. Management of ILO starts by establishing an accurate diagnosis, and treatment includes control of trigger factors, breathing and relaxation techniques, and speech and respiratory therapy. The aim of this article is to summarise current understanding and provide a review of the literature of ILO in the paediatric population.
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Ghaemi H, Khoddami SM, Soleymani Z, Zandieh F, Jalaie S, Ahanchian H, Khadivi E. The Vocal Fold Dysfunction Questionnaire: Validity and Reliability of the Persian Version. J Voice 2017; 32:710-714. [PMID: 29284560 DOI: 10.1016/j.jvoice.2017.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/12/2017] [Accepted: 08/22/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study was to develop, validate, and assess the reliability of the Persian version of Vocal Cord Dysfunction Questionnaire (VCDQP). STUDY DESIGN The study design was cross-sectional or cultural survey. MATERIALS AND METHODS Forty-four patients with vocal fold dysfunction (VFD) and 40 healthy volunteers were recruited for the study. To assess the content validity, the prefinal questions were given to 15 experts to comment on its essential. Ten patients with VFD rated the importance of VCDQP in detecting face validity. Eighteen of the patients with VFD completed the VCDQ 1 week later for test-retest reliability. To detect absolute reliability, standard error of measurement and smallest detected change were calculated. Concurrent validity was assessed by completing the Persian Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) by 34 patients with VFD. Discriminant validity was measured from 34 participants. The VCDQ was further validated by administering the questionnaire to 40 healthy volunteers. Validation of the VCDQ as a treatment outcome tool was conducted in 18 patients with VFD using pre- and posttreatment scores. RESULTS The internal consistency was confirmed (Cronbach α = 0.78). The test-retest reliability was excellent (intraclass correlation coefficient = 0.97). The standard error of measurement and smallest detected change values were acceptable (0.39 and 1.08, respectively). There was a significant correlation between the VCDQP and the CAT total scores (P < 0.05). Discriminative validity was significantly different. The VCDQ scores in patients with VFD before and after treatment was significantly different (P < 0.001). CONCLUSIONS The VCDQ was cross-culturally adapted to Persian and demonstrated to be a valid and reliable self-administered questionnaire in Persian-speaking population.
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Affiliation(s)
- Hamide Ghaemi
- Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyyedeh Maryam Khoddami
- Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Soleymani
- Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran.
| | - Fariborz Zandieh
- Department of Pediatric, School of Medical, Tehran University of Medical Sciences, Tehran, Iran
| | - Shohreh Jalaie
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Ahanchian
- Department of Pediatrics, School of Medical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Khadivi
- Department of Otorhinolaryngology, School of Medical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
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Hull JH, Backer V, Gibson PG, Fowler SJ. Laryngeal Dysfunction: Assessment and Management for the Clinician. Am J Respir Crit Care Med 2017; 194:1062-1072. [PMID: 27575803 DOI: 10.1164/rccm.201606-1249ci] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The larynx is one of the most highly innervated organs in humans and serves a number of vitally important, complex, and highly evolved biological functions. On a day-to-day basis, the larynx functions autonomously, addressing several roles including airway protection, swallowing, and phonation. In some situations the larynx appears to adopt a functional state that could be considered maladaptive or "dysfunctional." This laryngeal dysfunction can underpin and account for a number of respiratory symptoms that otherwise appear incongruous with a clinical disease state and/or contribute to the development of symptoms that appear "refractory" to treatment. These include conditions associated with a heightened tendency for inappropriate laryngeal closure (e.g., inducible laryngeal obstruction), voice disturbance, and chronic cough. Recognition of laryngeal dysfunction is important to deliver targeted treatment and failure to recognize the condition can lead to repeated use of inappropriate treatment. Diagnosis is not straightforward, however, and many patients appear to present with symptoms attributable to laryngeal dysfunction, but in whom the diagnosis has been overlooked in clinical work-up for some time. This review provides an overview of the current state of knowledge in the field of laryngeal dysfunction, with a focus on pragmatic clinical assessment and management.
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Affiliation(s)
- James H Hull
- 1 Department of Respiratory Medicine, Respiratory Biomedical Research Unit, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Vibeke Backer
- 2 Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Peter G Gibson
- 3 Centre for Healthy Lungs, University of Newcastle, Newcastle, United Kingdom.,4 Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, United Kingdom.,5 Hunter Medical Research Institute, Newcastle, Australia
| | - Stephen J Fowler
- 6 Centre for Respiratory Medicine and Allergy, University of Manchester, Manchester, United Kingdom; and.,7 Manchester Academic Health Science Centre, Manchester, United Kingdom
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Smith B, Milstein C, Rolfes B, Anne S. Paradoxical vocal fold motion (PVFM) in pediatric otolaryngology. Am J Otolaryngol 2017; 38:230-232. [PMID: 28139319 DOI: 10.1016/j.amjoto.2017.01.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 01/22/2017] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Paradoxical vocal fold motion (PVFM) is a condition in which the vocal cords exhibit inappropriate inspiratory adduction, and it has been poorly studied in the pediatric population. METHODS Pediatric patients diagnosed with PVCM by a pediatric otolaryngologist and doctor of speech pathology from 2008 to 2012 were reviewed. Patients in whom another cause for their respiratory disturbance was eventually identified were excluded. Patient demographics, characteristics, treatment, and outcomes were reviewed. The study was approved by the Institutional Review Board at our institution. RESULTS Thirty patients met criteria for inclusion; one with chiari malformation was excluded. 17/29 (59%) were female. Body mass index (BMI) numbers ranged from 16 to 25 with a mean of 21. 9/29 (31%) competed at the highest level of a sport; only 3/29 (10%) did not participate in athletics. Average age of onset was 12.0years; average diagnosis delay was 1.3years. Mean follow up was 2.3years. 24/29 (83%) were previously treated for asthma. 23/29(79%) were previously treated for reflux. 25/29(86%) completed at least one session of respiratory and laryngeal control therapy with overall average of 2.2 sessions completed. All patients who attended a second therapy session were recorded as having improvement in symptoms. CONCLUSIONS Pediatric patients with PVFM often participate in high levels of organized sports and the frequency of concurrent asthma and reflux symptoms in this population supports the theory that laryngeal hypersensitivity contributes to the pathophysiology of PVFM. These patients were not found to have any associated psychiatric diagnoses. Pediatric patients with PVFM have an excellent prognosis when treated with speech therapy and for comorbid conditions as indicated.
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Affiliation(s)
- Blake Smith
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, United States.
| | - Claudio Milstein
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, United States
| | - Bryan Rolfes
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, United States
| | - Samantha Anne
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, United States
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Denipah N, Dominguez CM, Kraai EP, Kraai TL, Leos P, Braude D. Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction). Ann Emerg Med 2017; 69:18-23. [PMID: 27522309 DOI: 10.1016/j.annemergmed.2016.06.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/27/2016] [Accepted: 06/28/2016] [Indexed: 11/25/2022]
Abstract
Paradoxical vocal fold motion disorder, also commonly termed vocal cord dysfunction, is a poorly understood cause of acute upper airway obstruction. Patients with paradoxical vocal fold motion frequently present to the emergency department (ED) with acute respiratory distress and stridor. Lack of familiarity with this disorder may lead to delayed diagnosis or misdiagnosis and unnecessary intubations or surgical airway procedures. Although long-term management of paradoxical vocal fold motion is well described, there is a paucity of information about acute evaluation and management. This article aims to summarize the ED presentation and management of paradoxical vocal fold motion.
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Affiliation(s)
- Nizhoni Denipah
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Christopher M Dominguez
- Division of General Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Erik P Kraai
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Tania L Kraai
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Paul Leos
- Department of Speech Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Darren Braude
- Departments of Emergency Medicine and Anesthesiology, University of New Mexico Health Sciences Center, Albuquerque, NM.
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Atopic characteristics of patients with vocal cord dysfunction. Ann Allergy Asthma Immunol 2016; 118:228-230. [PMID: 27939842 DOI: 10.1016/j.anai.2016.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/26/2016] [Accepted: 10/31/2016] [Indexed: 11/24/2022]
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Affiliation(s)
- Jaclyn A Smith
- Division of Infection Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK.,University Hospital of South Manchester, Manchester, UK
| | - Jemma Haines
- University Hospital of South Manchester, Manchester, UK
| | - Janelle Yorke
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.,The Christie NHS Foundation Trust, Manchester, UK
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