Vocal cord dysfunction in children and adolescents

Effects of Exercise-Induced Laryngeal Obstruction in Adolescents: A Qualitative Study

PURPOSE

The purpose of this study was to examine the influence of exercise-induced laryngeal obstruction (EILO) on adolescents.

METHOD

Twenty patients (< 17 years) diagnosed with EILO participated in this study. Patients completed semistructured interviews examining their experience with the health care system, treatment, and the effects of EILO symptoms on quality of life. Interviews were analyzed using a combination of directed and conventional content analyses. Researchers identified seven overarching themes either prior to or during analysis, and 24 subthemes were inductively identified from patient interviews using open, axial, and selective coding.

RESULTS

On average, patients went 1.9 years between symptom onset and EILO diagnosis. Patients described symptom onset as frightening and confusing. Even after initially reporting symptoms to a medical provider, patients went an average of 10.5 months before diagnosis. Patients perceived that delays in diagnosis prevented efficient management and allowed symptoms to escalate. Patients reported that EILO detrimentally influenced athletic performance, forcing them to pace themselves or cease participation altogether. Social and academic effects of EILO included missed classes, difficulty in physical education courses, and resentment from teammates if athletic performance declined. Both athletes and nonathletes indicated that EILO elicited feelings of fear, frustration, dread, guilt, and embarrassment. Patients reported that therapy with a speech-language pathologist (SLP) effectively addressed symptoms; however, employing rescue breathing techniques was often more difficult than anticipated.

CONCLUSIONS

Physical and emotional sequelae associated with EILO may have widespread influence on patient quality of life. Therapy with an SLP reportedly ameliorated EILO symptoms; however, patients indicated that delayed diagnosis allowed negative effects to intensify prior to treatment.

Exploring Mental Health in a Pediatric Paradoxical Vocal Fold Motion Sample Using Patient-Reported Outcomes

OBJECTIVE

Paradoxical vocal fold motion (PVFM) is characterized by inappropriate adduction of vocal folds during inspiration causing dyspnea. While anxiety is suspected to be a predisposing factor, incidence has been understudied.

STUDY DESIGNS

Retrospective review.

SETTING

Multidisciplinary PVFM hospital clinic.

METHODS

We used patient-reported outcome measures to examine anxiety and depression in consecutive patients aged 10 to 17 years using Pediatric SFv1.1 Anxiety 8b and Level 2-Depression inventories (parents completed proxy forms). T-scores were classified as normal (none to slight <55) or elevated (mild 55-59.9, moderate 60-69.9, severe >70).

RESULTS

Twenty-three pediatric patients and 20 parents completed surveys. Mean age was 13.74 years. For anxiety, 69.6% of patients and 40% of parents identified elevated levels. For depression, 30.4% of patients and 15% of parents identified elevated levels. Therapy need for the sample was 65.2% (34.8% active in services and 30.4% referred). Child anxiety scores were significantly higher in the therapy need group, U = 17, P = .004.

CONCLUSION

This study of adolescents with PVFM confirmed elevated anxiety and depression scores in 2/3 of the participants. Anxiety likely precedes diagnosis and is a predisposing factor. Referral for individualized intervention targeting anxiety and depression is indicated.

Clinical Profiles of Children and Adolescents With Induced Laryngeal Obstruction (ILO) and Exercise Induced Laryngeal Obstruction (EILO)

PURPOSE

To compare clinical profiles of pediatric patients with Induced Laryngeal Obstruction (ILO), Exercise Induced Laryngeal Obstruction (EILO), and EILO with non-exertion related secondary triggers (EILO+).

METHODS

A retrospective observational cohort design was employed. Four-hundred and twenty-three patients <18 years of age were identified from the electronic medical record of a large children's hospital. All patients underwent evaluations with a laryngologist and speech-language pathologist and were diagnosed with EILO/ILO. Patients were divided into 3 groups based on dyspnea triggers reported in initial evaluations. Groups consisted of patients with EILO (N = 281), ILO (N = 30), and EILO+ (N = 112). Patient demographics, EILO/ILO symptoms, endoscopy findings, medical comorbidities, medical history, and EILO/ILO treatment information were extracted and compared across EILO/ILO subtypes.

RESULTS

Patients with EILO experienced higher rates of hyperventilation (P < .001), sore throat (P = .023), and chest pain (P = .003). Patients with ILO were significantly younger in age (P = .017) and presented with increased rates of nighttime symptoms (P < .001), globus sensation (P = .008), self-reported reflux symptoms (P = .023), and history of gastrointestinal conditions (P = .034). Patients with EILO+ were more likely to be female (P = .037) and presented with higher prevalence of anxiety (P = .003), ADHD (P = .004), chest tightness (P = .030), and cough (P < .001).

CONCLUSIONS

Patients with EILO, ILO, and EILO+ present with overlapping but unique clinical profiles. A prospective study is warranted to determine the etiology of these differences and clarify how the efficacy of EILO, ILO, and EILO+ treatment can be maximized.

LEVEL OF EVIDENCE

4.

Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction

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.

Factors impacting therapy duration in children and adolescents with Paradoxical Vocal Fold Movement (PVFM)

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.

The Association between Paradoxical Vocal Fold Motion and Dysphonia in Adolescents

OBJECTIVE

Associations between dysphonia and paradoxical vocal fold motion (PVFM) have been previously reported in adults, but it is unclear whether similar associations exist for adolescents. The goals of this study were to identify the prevalence and severity of voice disorders in adolescent patients with PVFM, identify differences between those with and without clinician-identified dysphonia, and investigate what factors were associated with voice handicap in this population.

METHODS

A retrospective review of eligible adolescent patients diagnosed with PVFM over a 1-year period at a single institution was undertaken. Data collected from the medical record included demographic background, medical history and workup, patient- and family-reported symptoms, and findings from the laryngeal examination. The presence or absence of clinician-diagnosed dysphonia was used to subdivide the sample for analysis.

RESULTS

Forty-eight patients with PVFM were included. The sample was primarily female (73%) with a median age of 15 years. Few patients had voice complaints (5%), but clinician-diagnosed dysphonia was common (52%) and ranged from mild to moderate. Vocal hyperfunction was frequently observed (55%), but anatomic abnormalities associated with dysphonia were rare (6%). Adolescents with dysphonia were significantly older, more likely to have vocal hyperfunction on laryngoscopy, and more likely to return for therapy than those without dysphonia. No notable differences existed in the number of behavioral therapy sessions or in the likelihood of completing treatment between the two groups. The majority of participants (79%) had at least one "confounding factor" (i.e., were currently taking a medication for asthma, allergies, or reflux, or had a laryngeal abnormality) but this did not differ significantly between those with and without dysphonia. A minority of individuals (28%) had abnormal scores on the Voice Handicap Index (VHI). Age was positively correlated with dysphonia severity but no other significant associations were observed.

CONCLUSION

Although voice complaints are rare, dysphonia among adolescents with PVFM is common and can occur in the absence of laryngeal abnormalities and medical comorbidities, typically as a result of vocal hyperfunction. Dysphonia does not appear to be a barrier to PVFM treatment and may be a useful target in therapy.

Gasping for a Diagnosis: Pediatric Vocal Cord Dysfunction

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.

Vocal cord dysfunction and bronchial asthma

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.

Inducible Laryngeal Obstruction in the Paediatric Population – Review of the Literature and Current Understanding

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.

Differentiating vocal cord dysfunction from asthma

Vocal cord dysfunction (VCD)-associated symptoms are not rare in pediatric patients. Dyspnea, wheezing, stridor, chest pain or tightness and throat discomfort are the most commonly encountered symptoms. They may occur either at rest or more commonly during exercise in patients with VCD, as well as in asthmatic subjects. The phase of respiration (inspiration rather than expiration), the location of the wheezing origin, the rapid resolution of symptoms, and the timing occurring in relation to exercise, when VCD is exercise induced, raise the suspicion of VCD in patients who may have been characterized as merely asthmatics and, most importantly, had not responded to the appropriate treatment. The gold standard method for the diagnosis of VCD is fiberoptic laryngoscopy, which may also identify concomitant laryngeal abnormalities other than VCD. However, as VCD is an intermittent phenomenon, the procedure should be performed while the patient is symptomatic. For this reason, challenges that induce VCD symptoms should be performed, such as exercise tests. Recently, for the evaluation of patients with exercise-induced VCD, continuous laryngoscopy during exercise (such as treadmill, bicycle ergometer, swimming) was used. A definite diagnosis of VCD is of importance, especially for those patients who have been erroneously characterized as asthmatics, without adequate response to treatment. In these cases, another therapeutic approach is necessary, which will depend on whether they suffer solely from VCD or from both conditions.

Exercise-induced bronchoconstriction update-2016

The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.

Breathing-related changes of respiratory resistance in vocal cord dysfunction

Vocal cord dysfunction induced by exercise in children with uncontrolled asthma was identified by laryngoscopy. The paradoxical adduction of the vocal cords was also indicated by the breathing-related changes of the forced oscillation respiratory resistance showing prominent increase during inspiration and a large positive difference between inspiration and expiration. The breathing-related changes of respiratory resistance offer thus a useful first-line technique to diagnose vocal cord dysfunction.

[Spirometry patterns in vocal cord dysfunction]

INTRODUCTION

Vocal cord dysfunction (VCD) is a rare disease characterized by a paradoxical closure of the vocal cords, usually in inspiration, that causes dyspnea and stridor. The spirometry pattern that is more often described is a plateau in the inspiratory curve, but it can be also found in the expiratory loop The aim of this study was to evaluate the most common spirometry characteristics of patients with VCD and, secondarily, to describe the clinical and demographic characteristics and the treatment of patients with a definitive diagnosis of this disease.

MATERIAL AND METHODS

A retrospective study was made of cases of VCD between 2000 and 2010. Diagnosis was considered definitive when a paradoxical closure of the vocal cords became clear on laryngoscopy. Exercise challenge on a treadmill was performed to produce symptoms. Demographic and clinical data were collected, and flow-volume curves were studied.

RESULTS

Of 36 suspected cases, VCD was confirmed in 11 (30.5%). The mean age was 13.5 years, 10 were female. Possible triggers were found in 5 patients. Six patients had a previous history of asthma. All patients had a plateau in the inspiratory curve, and 9 (81%) of them also in the expiratory loop. Only 4 patients had a ratio between maximum inspiratory and expiratory flows at 50% of forced vital capacity (MEF50%/MIF50%) > 2.2.

CONCLUSIONS

Although the most frequent spirometry pattern in VCD is a plateau in the inspiratory curve, a significant percentage of patients also have a plateau in the expiratory curve. This could invalidate the MEF50%/MIF50% ratio for the diagnosis of VCD.

Vocal cord dysfunction in adolescents

RATIONALE FOR THE STUDY

Vocal cord dysfunction (VCD) often presents with dramatic and abrupt symptoms. To diagnose VCD, visualization by direct laryngoscopy is required and because patients are usually asymptomatic, a specific method to provoke VCD is needed. Approaches to predict VCD by alterations of the flow-volume loop have been investigated.

METHODS

Adolescents with clinical suspicion of VCD were invited to participate. After an initial pulmonary function test (PFT), direct laryngoscopy was performed. This was followed by a methacholine challenge test (MCT); the methacholine dose causing a 20% drop in forced expiratory volume after 1 sec (FEV(1) ) (PD(20) FEV(1) ) was calculated. Then a second laryngoscopy was conducted. PFT changes before and after MCT were compared with the data of 14 healthy controls (HCs).

RESULTS

Thirty-five patients (8-19 years) were investigated. Three showed anatomical alterations. Of the remaining 32 patients, 14 had VCD and 18 had bronchial hyperresponsiveness (non-VCD). In 29 patients with a positive MCT, PD(20) FEV(1) methacholine was significantly lower in VCD compared with non-VCD (VCD 0.24 ± 0.4 mg, non-VCD 0.73 ± 0.73 mg, P = 0.0006). A PD(20) FEV(1)  < 0.24 mg methacholine predicted VCD with a sensitivity of 85% and a specificity of 75%. VCD patients showed significantly lower PFT parameters after challenge; FEV(1) : VCD 58.5 ± 20.1%, non-VCD 80.2 ± 18.0%, and HCs 98.7 ± 16.6% (P < 0.0001).

CONCLUSIONS

The combination of MCT and laryngoscopy may be able to differentiate between VCD and non-VCD. VCD patients showed a positive reaction at lower methacholine doses and displayed greater airway obstruction after MCT. PFTs and MCT do not replace direct laryngoscopy in the diagnosis of VCD in adolescents.

Vocal cord dysfunction in athletes: clinical presentation and review of the literature

Vocal cord dysfunction (VCD) is a syndrome characterized by the intermittent, abnormal paradoxical adduction of the true vocal cords during respiration resulting in variable upper airway obstruction. It is also commonly referred to as paradoxical vocal fold motion disorder. Patients with VCD usually present with intermittent shortness of breath of varying intensity, wheezing, stridor, choking, throat tightness, voice changes, or cough, and these symptoms often resolve quickly after relaxation or cessation of activity. Since first described as a distinct clinical entity in 1983, VCD remains underrecognized and the underlying cause(s) is not fully understood. Several studies suggest psychogenic or laryngeal hyperresponsiveness as possible underlying causes. Although VCD may have many causes, it can be a unique problem, especially in athletes because it often mimics and can be easily mistaken for exercise-induced bronchospasm, which may result in unnecessary medical treatment and delay in diagnosis. A detailed history, physical examination, and pulmonary function tests with flow-volume loops are important for excluding other diagnoses; however, the gold standard method for diagnosing VCD is by observation of the vocal cords with flexible laryngoscopy. The mainstay of treatment includes behavioral management guided by a speech-language pathologist, but optimal therapy often requires a multidisciplinary team involving a variety of specialties, including certified athletic training, pulmonology, otolaryngology, speech-language pathology, gastroenterology, allergy and immunology, and psychology, as appropriate. We reviewed the medical literature for VCD specifically in athletes, and this article discusses in detail the definition, epidemiology, possible pathophysiology, diagnosis, and treatment options.

Vocal cord dysfunction: an update

OBJECTIVES

To review the clinical manifestations of vocal cord dysfunction (VCD) and to discuss new developments in the diagnosis and treatment.

DATA SOURCES

PubMed searches were performed for articles published regarding presentation, pathogenesis, diagnosis, and treatment options of VCD using the keywords vocal cord dysfunction, pathogenesis, clinical features, diagnosis, and management.

STUDY SELECTION

Articles were selected based on their relevance to the topic of this review. The newest developments in VCD were defined by articles published in the past 8 years.

RESULTS

The exact cause and pathogenesis remain unclear, although laryngeal hyperresponsiveness likely plays a role in a subset of patients. Certain findings on spirometry are often interpreted to suggest VCD, but recent studies have had varying results on how useful these are in the diagnosis of VCD. Diagnosis is made by direct visualization of the adduction of the vocal cords via rhinolaryngoscopy, but the method used to provoke symptoms and adduction varies. Other noninvasive tests have been evaluated as well.

CONCLUSION

The early recognition and treatment of VCD are imperative to prevent the misdiagnosis and mismanagement of asthma. In addition, VCD and asthma can occur together. The origin and pathogenesis of VCD need to be better defined. More studies comparing the provocation methods during laryngoscopy may be helpful in further standardizing a diagnostic test. Further research is needed to determine whether other noninvasive tests are as effective in diagnosing VCD as laryngoscopy.

Diagnosis and management of asthma in adolescents

OBJECTIVES

In this review we explore some of the issues surrounding the diagnosis and misdiagnosis of asthma in adolescents and suggest a management approach which might facilitate the provision of optimal treatment in order to minimise morbidity from asthma in this vulnerable and often difficult-to-manage age group.

RESULTS

We highlight important diagnostic traps which occur in the adolescent age group, including the misdiagnosis of asthma in young people presenting with exercise-related symptoms or cough, and stress the importance of considering alternative diagnoses, including vocal cord dysfunction. We explore how adolescence impacts on asthma management and emphasise the importance of an understanding of normal adolescent development and an awareness of high-risk indicators in developing a strategy to optimally manage a young person with asthma. We also illustrate how psychosocial functioning may impact on both perceived asthma severity and quality of life as well as interfere with optimal asthma control both directly and by increasing non-adherence. A suggested management strategy for adolescents is provided which emphasises a supportive approach to help facilitate optimal control of asthma by involving the young person in management decisions about their asthma. Specific mention is made about smoking cessation assistance and the interrelationship between physical activity, obesity and asthma. Finally we discuss the importance of an appropriate transition process to prepare the young person for transfer from child-centred care to adult-centred care.

CONCLUSION

Many different factors is of outmost importance when diagnosing adolescents with shortness of breath; furthermore, management of asthma need a supportive approach in both paediatric and adult setting.

[Diagnosis and treatment guidelines for difficult-to-control asthma in children]

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.

[Expiratory vocal cord dysfunction? Case report and review of the literature]

Wood and Milgrom defined vocal cord dysfunction (VCD) as paradoxical adduction of the vocal folds during inspiration or during inspiration and expiration. We describe the case of a patient with attacks of dyspnea with an isolated expiratory paradoxical adduction of the vocal folds. A review of the literature reveals many factors associated with VCD. Because of the similar risk factors and order of events concerning VCD, we believe that even expiratory laryngeal dysfunctions could be denoted as subtypes of VCD.

Management of vocal paralysis: a comparison of adult and pediatric practices

OBJECTIVE

To compare practices of the American Broncho-Esophagological Association (ABEA) membership regarding the evaluation and management of unilateral vocal fold motion impairment (UVFMI) in adult versus pediatric populations.

STUDY DESIGN AND SETTING

An 18-item adult survey and 16-item pediatric survey were administered to ABEA members.

RESULTS

Seventy-six adult (31%) and 35 pediatric surveys (43%) were completed. Key differences are highlighted. With respect to etiology, the most common reported childhood cause is idiopathic; adults more often suffer iatrogenic paralysis. Children more commonly experience reflux disease, feeding difficulties, and choking. Preferred testing involves flexible laryngoscopy and chest x-ray; however, laboratory tests are carried out less often in children (51% vs 71%) and medical intervention is advocated by fewer pediatric practitioners (39% vs 57%).

CONCLUSION

Significant disparities exist in the etiology, presenting symptoms, diagnostic testing, and medical treatment between children and adults with UVFMI.

SIGNIFICANCE

Clinicians' perceptions regarding UVFMI may reflect the differing impact of vocal paralysis in the pediatric versus adult populations.

Long-term outcome of vocal cord dysfunction

BACKGROUND

Vocal cord dysfunction (VCD) is an involuntary functional disorder commonly misdiagnosed as asthma. Previous reports describe the disorder and treatment but not the long-term outcome.

OBJECTIVE

To determine the long-term outcome of VCD.

METHODS

A retrospective medical record review identified 49 patients, ages 8 to 25 years, diagnosed as having VCD from 1989 to 2002. Telephone contact was attempted in all.

RESULTS

Of the 49 patients, 41 had previously been treated for asthma; that diagnosis was confirmed by us as a comorbidity in only 12 patients. Two distinct phenotypes of VCD were observed. Symptoms were limited to exercise-induced VCD (EIVCD) in 29 and spontaneously occurring VCD (SVCD) in 20, only 4 of whom additionally had EIVCD. Twenty-eight of the 49 were successfully contacted by telephone. Eight of the 11 contacted patients with SVCD followed the recommendation to see our speech therapist, all of whom learned to control symptoms. However, 2 who also had EIVCD continued with that problem. Pretreatment with an anticholinergic inhaler prevented EIVCD in 6 patients in whom this was tried. Complete absence of symptoms, at times ranging from 1 week to 5 years (median, 5 months), was reported in 26 of the 28 contacted patients.

CONCLUSIONS

VCD continues to be frequently misdiagnosed as asthma. Two phenotypes of VCD are apparent: EIVCD and SVCD. Speech therapy provides relief of symptoms for SVCD. Prevention of EIVCD with an anticholinergic inhaler in 6 patients suggests that a controlled clinical trial is warranted. Regardless of treatment, eventual spontaneous resolution was common.

Making the diagnosis of asthma in the athlete

This article encompasses a discussion of the clinical presentation and features as various diagnostic modalites of bronchoprovocation and differential diagnosis used in screening for asthma in the athlete. A comparative analysis of these modalities, including questionnaire, treadmill, eucapneic hyperventilation, as well as field challenge, is provided with sensitivities and specificities, predictive value, and application to clinical practice. The indication and mechanics of each diagnostic modality is discussed, providing the clinician with a comprehensive understanding of the principles and procedures used to diagnosis asthma in the athlete.

Differential diagnosis of adult asthma

Although the term "all that wheezes is not asthma" is not new, and the long list of asthma masqueraders has remained essentially the same for several decades, the importance of knowing when to question the accuracy ofa diagnosis of asthma has remained critical for physicians who care for patients with respiratory symptoms. The concepts of "asthma control" and"asthma severity" are currently evolving, although the fundamental hall-marks that define the syndrome of asthma endure and should be mastered by asthma specialists. Asthma masqueraders, including several that may confound a correct diagnosis of asthma, are important to consider when either the presentation of asthma is atypical or the response of the patient to treatment is suboptimal. COPD and VCD head the list of diagnoses most likely to be confused with asthma in everyday practice. Correctly identifying the diagnosis of COPD enables implementation of an up-to-date treatment plan that differs from asthma management. VCD is a vastly under recognized syndrome whose existence is widely accepted but whose pathophysiology is poorly understood, and correctly identifying a VCD component to asthma symptoms enables both a reduction in costly and potentially harmful asthma medications and focus on specific VCD treatment, such as speech therapy. For less common and uncommon asthma masqueraders, it is important to be familiar with their typical clinical presentation and basic diagnostic approaches.