Anita Gheller-Rigoni, DO, FACAAI

Allergist-Immunologist

Exercise-Induced

Vocal Cord Dysfunction

Objectives

• 1. Understand the concept of vocal cord dysfunction

• 2. Recognize the difference between exercised induced bronchospasm and exercise induced vocal cord dysfunction

• 3. Identify acute treatment interventions for exercise induced vocal cord dysfunction

• 4. Understand the long term management of vocal cord dysfunction

Normal Respiration

• On inhalation, the vocal cords (folds) ABduct allowing air to flow into the lungs

• On exhalation, the vocal folds may close slightly, however mainly remain ABducted

Definition – Vocal Cord Dysfunction

A disorder of the upper airway in which the vocal folds ADduct during inspiration, exhalation, or both. This can result in inspiratory stridor and respiratory distress.

Vocal Cord Anatomy

Vocal fold ABDuction - respiration

Vocal fold ADDuction - speech

Vocal fold ADDUCTION

Occurs during

swallowing, coughing, etc…

Pseudonyms

• Paradoxical vocal fold motion (PVFM)

• Vocal cord dysfunction (VCD)

• Psychogenic stridor

• Munchausen’s stridor

• Emotional laryngeal wheezing

• Pseudo-asthma

• Fictitious asthma

• Episodic laryngeal dyskinesia

Clinical Presentation

• Stridor (particularly on inhalation)

• Audible wheeze

• Choking sensation

• Acute episodic shortness of breath

• Voice weakness or loss

• Tightness in throat with substernal chest pain

• Globus Sensation

• Difficulty “getting air in”

Triggers

• Exercise

• Chemical odors

• Cigarette smoke

• Perfumes

• Cold air

• Stress

• Respiratory tract infections

Comorbidities

• Asthma

• Allergic rhinitis

• Gastroesophageal reflux disease

• Anxiety

• Neurological issues

• Overuse (singers, speakers, etc.)

Clinical Presentation –Athletes

• SOB out of proportion to level of physical endurance

• Complain that they “can’t get enough air in”

• Throat tightening > bronchial/ chest

• Abrupt onset and resolution (with rest)

• Little or NO response to medical treatment (inhalers, bronchodilators)

VCD vs EIB

VCD

• Onset: at rest or later

• Sxs: throat/substernal

• Sx increased w/inspiration

• Quick onset & resolution

• Most inhalers do NOT help

EIB

• Onset: early in activity

• Sxs: whole chest

• Sx increased w/expiration

• Can persist 30 min to hours

• Albuterol helps

• Other co-morbidities: hx of asthma, allergies, pneumonia

VCD vs EIB

• Overlap of the two is common and up to 50% of individuals with VCD also have some type of asthma.

• Other causes of laryngeal obstruction

- bilateral vocal fold paralysis

- laryngeal stenosis

Diagnosis - VCD

Diagnosis - VCD

• Rule out all other causes

• Direct laryngoscopic visualization of the vocal cords

- After intense exercise

- After methacholine bronchoprovacation testing

Diagnostic Evaluation

Laryngoscopic Examination

• alternatively phonate and sniff, rapidly

• take deep breaths

• cough, throat clear, chuckle

• count to fifty, rapidly and loudly

• read a written passage in a loud voice

• sing

Direct Visualization

Acute Management of EI-VCD

• During an episode, they usually feel helpless and terrified

• Implying that it is “in their head” is incorrect and counterproductive to their recovery

• Facilitative diaphragmatic breathing- “belly breathing”

• Coach them through, help them out- “breath through it”

Acute Management of EI-VCD

- Sniff then Blow….talk the athlete through this

- Sniff in with focal emphasis at the tip of the nose

• Sniff = ABduction

- Then exhale with pursed lips on

• “ssssss”

• “shhhhhh”

• “ffffffff”

• = Back pressure respiration

Long Term Management

• Treat underlying causes- Medications for acid reflux or allergies

- Behavioral health

• Speech and language pathology

• Physical therapy

• Atrovent (ipratropium) inhaler before activity

Conclusions

• VCD is a family of syndromes

• In order to diagnose and treat VCD effectively a thorough history is important

• All relevant contributing factors should be addressed

• A psychogenic component does not rule out other organic etiologies

• A team approach is important