Functional stridor in adolescents

Practice Patterns in Speech-Language Pathologist Treatment of Induced Laryngeal Obstruction

PURPOSE

The goal of this study was to examine current speech-language pathologist (SLP) practice patterns in the diagnosis and treatment of induced laryngeal obstruction (ILO; both exercise- and irritant-induced variants: exercise-induced laryngeal obstruction [EILO]/ILO).

METHOD

One hundred ninety-one SLPs from throughout the United States were surveyed regarding practice patterns for diagnosing and treating EILO/ILO. SLPs were queried regarding diagnostic procedures, treatment practices, outcome measures, rescue breathing strategies utilized, and discharge criteria employed within their clinical practice. SLPs rated their confidence in treating EILO/ILO using a visual analog scale. Clinician confidence was compared across SLPs working in different settings, with different populations, and with varying access to diagnostic equipment/collaborators. Median income of facility neighborhood and clinician experience were also considered.

RESULTS

Most SLPs reported that patients with EILO/ILO were diagnosed using laryngoscopy (with or without videostroboscopy) either at rest or following exercise. Only 4.7% of respondents indicated that their patients had access to continuous laryngoscopy during exercise (CLE) for diagnosing EILO. The Dyspnea Index was the most common patient-reported outcome measure for both EILO and ILO. SLPs reported high confidence levels in rescue breathing techniques, and informal patient report was the most common method of tracking therapeutic progress. Forty-one percent of SLPs voiced the need for increased access to diagnostic equipment (CLE or laryngoscopy), and 51.8% expressed the need for exercise facilities (i.e., treadmills or places to have patients run). Clinicians reported significantly higher levels of confidence treating EILO as opposed to ILO (p < .001). Collaborating with a laryngologist (p < .001), more years of experience (p = .025), and wealthier median income of practice setting (p = .014) predicted increased confidence in treating EILO/ILO.

CONCLUSIONS

SLPs may have limited access to the most effective facilities and diagnostic equipment designed to identify EILO/ILO. Continuing research is needed to provide SLPs with evidence-based diagnostic procedures, treatment strategies, and outcome measures to enhance EILO/ILO intervention for all patients.

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.

LEVEL OF EVIDENCE: 3

Functional Outcomes after Behavioral Treatment of Paradoxical Vocal Fold Motion in Adults

OBJECTIVE

Paradoxical vocal fold motion (PVFM) is responsive to behavioral therapy, often resulting in a remission of symptoms, but little is known about whether treatment is beneficial with regard to PVFM-associated psychological symptoms or functional limitations. The goal of the study was to identify patient perceptions of the impact of treatment for PVFM and characteristics associated with treatment outcomes.

METHODS

A survey was conducted of all adults who had received at least 1 session of treatment for PVFM in our outpatient clinic over a 2-year period.

RESULTS

The 39 participants ranged in age from 18 to 82 and had received a median of 3 treatment sessions. At a median follow-up of 10 months following treatment, respondents reported improvements in a wide range of areas, including sports and leisure, daily activities, and social participation. The majority reported improvements in feelings of anxiety, helplessness, and control. Poorer outcomes were associated with more severe voice symptoms, fewer treatment sessions, and needing oral steroids for asthma control.

CONCLUSION

There was a reduction in a wide range of activity limitations after treatment. Feelings of control were strongly associated with positive outcomes. The therapy appeared to be equally effective for adults with exercise-induced and environmental variants of PVFM.

Mass Psychogenic Illness Presenting as Acute Stridor in an Adolescent Female Cohort

Objectives:

We describe a cohort of patients with an unusual presentation of stridor, their evaluation and management, and their outcome. We review the pertinent English-language literature.

Methods:

We performed a retrospective review of the records of 12 adolescent patients treated for acute-onset inspiratory stridor at the Departments of Otolaryngology-Head and Neck Surgery and Allergy and Immunology at the University of South Florida and the Department of Speech Pathology at the H. Lee Moffitt Cancer Center and Research Institute. Two additional patients received treatment elsewhere. Demographic, historical, and laboratory data, physical examination findings, and follow-up information were extracted. A review of both the Hillsborough County Department of Health epidemiological report and the English-language literature was performed.

Results:

Fourteen female patients who attended a local high school developed audible inspiratory noise. Twelve of the 14 were seen at the University of South Florida Ear, Nose and Throat Center. The remaining 2 patients were evaluated by outside otolaryngologists but were included in all reports from the Department of Health. Environmental studies did not find noxious chemical or biological agents in the students' environments to explain the development of the symptoms. Physical and videostroboscopic examination identified two distinct laryngeal findings causing the audible stridor. One involved paradoxical vocal fold movement, and the other, supraglottic mucosal collapse into the airway. All patients underwent rigorous speech pathology intervention and structured treatment with either complete resolution or significant improvement, seen both clinically and on videostroboscopic evaluation.

Conclusions:

Audible stridor can arise from numerous disease processes. In the vast majority of presentations it occurs sporadically and on an individual basis. Our cohort is especially unusual because of the sheer number of patients. Our presentation of a case of mass psychogenic illness as the cause of vocal cord dysfunction with additional findings of laryngomalacia within a group of adolescent girls is the first in the English-language literature. The key to the diagnosis is recognition of the disorder and susceptible individuals by using a thorough physical examination with emphasis on the laryngoscopic and videostroboscopic findings. The systematic approach, undertaken by a team including an otolaryngologist, an allergist, a speech pathologist, and an epidemiologist, proved to be effective in the management of this complex disorder and highly unusual situation.

Evidence-Based Systematic Review: Effects of Speech-Language Pathology Treatment for Individuals With Paradoxical Vocal Fold Motion

PURPOSE

In this article, our goal was to determine the state of the evidence and the effect of speech-language pathology (SLP) treatment for individuals with paradoxical vocal fold motion (PVFM).

METHOD

The American Speech-Language-Hearing Association's National Center for Evidence-Based Practice in Communication Disorders searched 22 electronic databases using key words related to PVFM, speech or voice treatment, and behavioral intervention for articles published through July 2013. Identified articles were systematically evaluated to assess the quality of the evidence using a modification of the American Speech-Language-Hearing Association's critical appraisal scheme.

RESULTS

Sixty-five articles met the search criteria. Only 2 out of the 65 articles were judged to contain adequate evidence to evaluate the effect of SLP treatment for PVFM. All 65 articles exemplify the state of the evidence for SLP treatment for PVFM.

CONCLUSION

The state of the evidence for the use of SLP treatment is in its infancy, with a majority of articles in the exploratory stage of research. Consequently, few clinical implications can be drawn at this time. SLP treatment for PVFM is promising; however, there is clearly a pressing need for systematic experimental studies that involve a control group to further the evidence base.

Vocal cord dysfunction in bronchial asthma. A review article

INTRODUCTION

Vocal cord dysfunction (VCD) is a condition in which the larynx exhibits paradoxical vocal cord adduction during inspiration, resulting in extra-thoracic variable airway obstruction. It has been described as a mimic of asthma, and hence, many patients with VCD are diagnosed as difficult-to-treat asthma and suffer significant morbidity as such.

METHODS

In completing this review we searched the literature using the database from MEDLINE, PubMed, and the Cochrane library using the medical terms "vocal cord/vocal cord dysfunction and asthma".

RESULTS

During the last few decades, many publications have described many conditions that may cause or coexist with VCD. In addition, the association between asthma and VCD was recognized. In this narrative review we provide an overview of the current knowledge about VCD and, in particular its relationship to asthma. We also provide a pragmatic diagnostic algorithm and treatment options based on our collaborative multi-disciplinary management of patients attending a difficult to control asthma clinic.

CONCLUSION

Most VCD patients present with inadequately controlled asthma rather than the typical symptoms described in association with VCD. Careful diagnostic strategy as outlined in this review may be helpful in confirming the diagnosis.

Behavioral Management of Paradoxical Vocal Fold Motion

Paradoxical vocal fold motion (PVFM), or vocal cord dysfunction (VCD), is a non-organic, behavioral, upper airway disorder primarily characterized by adduction of the true vocal folds during respiration. Recognition of this condition is becoming more prevalent amongst physicians, resulting in an increased number of referrals to speech-language pathologists (SLPs) for assessment and treatment. Diagnosis of PVFM requires a multidisciplinary approach. Treatment for PVFM is also multi-factorial, but is primarily designed to train abduction of the vocal folds during the breathing cycle, allowing easy movement of breath to and from the lungs without laryngeal constriction. Behavioral management is the preferred and most common approach to treatment and may include relaxed throat breathing and laryngeal control exercises during trigger-specific training.

Multidisciplinary approach to vocal cord dysfunction diagnosis and treatment in one session: a single institutional outcome study

OBJECTIVE

To determine whether the multidisciplinary approach to the management of vocal cord dysfunction (VCD), which combines patient education and behavioral intervention in the same session that VCD is diagnosed, provides long-term therapeutic benefits.

METHODS

Chart review and telephone interviews of patients treated for VCD at The Children's Hospital of Philadelphia were performed in this retrospective nonrandomized study. All forty patients diagnosed with VCD from October 2007 to April 2009 were included. Patients were evaluated with a multidisciplinary team approach, including speech therapy assessment, otolaryngology exam and flexible laryngoscopy. Patients with VCD were educated about their condition and instructed about breathing techniques in the same session.

RESULTS

Twenty-two patients were available for a phone interview. Mean age of patients was 13.4 ± 3.0 years. Sixteen patients were female. Mean number of clinic visits was 1.3 ± 0.8. Average time between phone interview and first clinical encounter was 14.0 ± 7.2 months. Compliance rate to demonstrate breathing exercises was 90.9%. Nineteen out of 22 patients (86.4%) reported improvement of their symptoms in frequency and/or severity. Six patients (27.3%) sought additional medical advice related to their respiratory symptoms. Twenty-one patients (95.5%) were able to maintain or increase their level of physical activity following clinic visit.

CONCLUSION

Combining the diagnostic encounter with multidisciplinary behavioral intervention in a single visit is an efficacious approach for the long-term management of VCD in the pediatric population.

Diagnostic criteria for the classification of vocal cord dysfunction

Vocal cord dysfunction (VCD) is a syndrome characterized by paroxysms of glottic obstruction due to true vocal cord adduction resulting in symptoms such as dyspnea and noisy breathing. Since first described as a distinct clinical entity in 1983, VCD has inadvertently become a collective term for a variety of clinical presentations due to glottic disorders. Despite an increased understanding of laryngeal function over the past 25 years, VCD remains a poorly understood and characterized entity. Disparities in the literature regarding etiology, pathophysiology, and management may be due to the historic approach to this patient population. Additionally, disorders clearly not due to paroxysms of true vocal cord adduction, such as laryngomalacia, vocal cord paresis, and CNS causes, need to be differentiated from VCD. Although a psychologic origin for VCD has been established, gastroesophageal reflux disease (GERD), nonspecific airway irritants, and exercise have also been associated with intermittent laryngeal obstruction with dyspnea and noisy breathing. VCD has been repeatedly misdiagnosed as asthma; however, the relationship between asthma and VCD is elusive. There are numerous case reports on VCD, but there is a paucity of prospective studies. Following an in-depth review of the medical literature, this article examines the available retrospective and prospective evidence to present an approach for evaluation of VCD including: (1) evaluation of factors associated with VCD, (2) differential diagnosis of movement disorders of the upper airway, and (3) clinical, spirometric, and endoscopic criteria for the diagnosis.

Laryngeal dyskinesia: an under-recognized condition

OBJECTIVE

To perform a review of the epidemiology, pathogenesis, clinical presentation, diagnosis and management of laryngeal dyskinesia.

METHODS

A search of the Medline database from 1966 to 2003 was performed. A manual search was performed of the references of each article.

RESULTS

Laryngeal dyskinesia is a respiratory condition characterized by abnormal vocal cord adduction and airflow limitation at the level of the larynx in the absence of evidence of local organic disease. It typically presents to the ED as wheeze, stridor or apparent upper airway obstruction. It occurs across a wide age range, is more common in females, and is typically associated with a range of underlying psychopathologies. Diagnosis is often delayed and unnecessary emergency treatment such as intubation and tracheostomy is not uncommon. Patients are commonly on high-dose steroids and are frequent users of the health-care system, often over prolonged periods. There are multiple diagnostic features on history and examination, and flexible nasendoscopy of the vocal cords in the ED can be used to confirm the diagnosis. Treatment options in the ED include sedation and use of continuous positive airway pressure. Long-term treatment involves a multidisciplinary approach involving respiratory physicians/ear, nose and throat surgeons, speech therapy and psychiatry.

CONCLUSION

Laryngeal dyskinesia remains an under-appreciated cause of respiratory presentations to the ED. Emergency physicians are ideally placed to make the diagnosis and initiate appropriate referral for specific therapies that have a high level of success.

Vocal cord dysfunction in children

Vocal cord dysfunction is characterised by paradoxical vocal cord adduction that occurs during inspiration, resulting in symptoms of dyspnoea, wheeze, chest or throat tightness and cough. Although the condition is well described in children and adults, confusion with asthma often triggers the use of an aggressive treatment regimen directed against asthma. The laryngoscopic demonstration of vocal cord adduction during inspiration has been considered the gold standard for the diagnosis of vocal cord dysfunction, but historical factors and pulmonary function findings may provide adequate clues to the correct diagnosis. Speech therapy, and in some cases psychological counselling, is often beneficial in this disorder. The natural course and prognosis of vocal cord dysfunction are still not well described in adults or children.

Paradoxical vocal cord motion--a dangerous imitator of airway emergencies

We report a case of stridor in a 32 year old woman. Initial laryngoscopy demonstrated adduction of the vocal cords on inspiration, which reverted to abduction on induction of general anaesthesia. The airway was structurally normal. The most likely diagnosis was paradoxical vocal cord motion, a condition in which psychological stress can precipitate respiratory symptoms and signs due to involuntary adduction of the vocal cords during inspiration. Its importance to the anaesthetist lies in its ability to masquerade as a serious airway or respiratory condition.

Paradoxical vocal fold motion in children and adolescents

Paradoxical vocal fold motion (PVFM) is a complex adductory disorder of the vocal folds that frequently is mistaken for asthma. PVFM typically requires behavioral intervention by a trained speech-language pathologist for complete resolution of the symptoms. Once thought to be limited to adults, PVFM has been increasingly documented and successfully treated in the child and adolescent population. Understanding PVFM requires thorough knowledge of the differential diagnoses, the clinical features of PVFM, the differentiation of PVFM from asthma, the medical professionals involved in the diagnosis and treatment, and the behavioral interventions that are commonly prescribed. Teachers, school nurses, and coaches may be the first professionals to see the symptoms in children and assume that they have asthma. Successful referral, diagnosis, and behavioral treatment requires a team of individuals in the child's community, including the school speech-language pathologist, who can work together to ensure identification and resolution of the symptoms. This article discusses etiologies, differential diagnosis, referral, medical management, evaluation, and behavioral treatment of the child or adolescent with PVFM.

Vocal cord dysfunction in children and adolescents

Vocal cord dysfunction (VCD) is a nonorganic disorder of the larynx that involves unintentional paradoxical adduction of the vocal cords while breathing. The resultant symptoms can include dyspnea, chest tightness, cough, throat tightness, wheezing, or voice change. Most patients with VCD are female, and among adolescents and children, VCD tends to be triggered by exercise and is typically confused with exercise-induced asthma. Both gastroesophageal reflux disease (GERD) and psychiatric illness have been reported as having strong associations with VCD, although, to date, there is no evidence that either causes VCD. VCD often coexists with asthma, and should be suspected in any patient in whom asthma treatment fails. Confirming the diagnosis involves direct visualization of abnormal vocal cord motion, and this usually only occurs during symptoms. Adolescent athletes often require free running exercise challenge to reproduce their symptoms and confirm abnormal vocal cord motion laryngoscopically. The primary treatment for VCD involves a combination of patient education and speech therapy, and, in most cases, patients may resume their activities without significant limitation.

Psychogenic Respiratory Distress: A Case of Paradoxical Vocal Cord Dysfunction and Literature Review

BACKGROUND: Pulmonary disease such as asthma is a psychosomatic disorder vulnerable to exacerbations precipitated by psychological factors. A case is described in which a patient thought to have treatment-refractory asthma was discovered to have a conversion reaction, specifically paradoxical vocal cord dysfunction (PVCD), characterized by abnormal vocal cord adduction during inspiration. DATA SOURCES: Reports of PVCD were located using a MEDLINE search and review of bibliographies. MEDLINE (English language only) was searched from 1966 through December 1998 using the terms functional asthma, functional upper airway obstruction, laryngeal diseases, Munchausen's stridor, paradoxical vocal cord dysfunction, psychogenic stridor, respiratory stridor, vocal cord dysfunction, and vocal cord paralysis. A total of 170 cases of PVCD were reviewed. STUDY FINDINGS: PVCD appears to be significantly more common among females. PVCD spans all age groups, including pediatric, adolescent, and adult patients. PVCD was most often misdiagnosed as asthma or upper airway disease. Because patients present with atypical and/or refractory symptoms, several diagnostic tests are employed to evaluate patients with PVCD; laryngoscopy is the most common. Direct visualization of abnormal vocal cord movement is the most definitive means of establishing the diagnosis of PVCD. A number of psychiatric disturbances are related to PVCD, including conversion and anxiety disorders. PVCD is associated with severe psychosocial stress and difficulties with modulation of intense emotional states. CONCLUSIONS: Psychogenic respiratory distress produced by PVCD can be easily misdiagnosed as severe or refractory asthma or other pulmonary disease states. Recognition of PVCD is important to avoid unnecessary medications and invasive treatments. Primary care physicians can detect cases of PVCD by attending to clinical symptoms, implementing appropriate laboratory investigations, and examining the psychological covariates of the disorder. Psychotherapy and speech therapy are effective in treating most cases of PVCD.

Psychosomatic problems and stress in adolescence

Psychosomatic problems are common in adolescents, and stress frequently plays a role in their development and maintenance. Armed with an understanding of the stressors experienced by adolescents, the individual's vulnerabilities and competencies and their level of social support, the physician can systematically assess each of these factors. Once the assessment is complete, a management plan can be formulated to address the particular psychosomatic problem. Symptom relief, stress reduction, and promotion of competence are important interventions that can be initiated by the primary care physician. When referrals are made for counseling and other stress management techniques, the primary care physician should maintain contact with the patient and family and remain an integral part of the management team. Incorporating brief discussions about the potential role of stress in health and illness into anticipatory guidance sessions may also help prevent the development of psychosomatic problems in adolescents.

A classification scheme for paradoxical vocal cord motion

Paradoxical vocal cord motion (PVCM) is characterized by the inappropriate adduction of the true vocal cords during inspiration. Multiple causes have been proposed for this group of disorders, which share the common finding of mobile vocal cords that adduct inappropriately during inspiration and cause stridor by approximation. Management of this group of disorders has been complicated by the lack of a classification scheme to include all types of PVCM. We propose that PVCM be classified according to its underlying etiology and recognize the following causes of the disorder: 1. brainstem compression; 2. cortical or upper motor neuron injury; 3. nuclear or lower motor neuron injury; 4. movement disorder; 5. gastroesophageal reflux; 6. factitious or malingering disorder; 7. somatization/conversion disorder. Case reports are presented to illustrate the characteristic features and diagnostic evaluation used in assessing patients with PVCM. Management varies depending on the cause of PVCM and entails speech therapy, pharmacologic therapy, behavioral modification, and/or surgical intervention. Recognition of the multiple causes of PVCM allows otolaryngologists to formulate well-directed diagnostic evaluation and treatment.

Paradoxical vocal cord motion presenting as acute stridor

We report the cases of two patients who presented with acute-onset stridor that did not respond to standard medical therapy. Both were eventually found to have paradoxical vocal cord motion (PVCM). The ED management of these patients is reviewed.