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

Diagnostic utility of spirometry for children with induced laryngeal obstruction or chronic non-specific cough

PURPOSE

To determine the diagnostic utility of spirometry in distinguishing children with Induced Laryngeal Obstruction (ILO) or chronic non-specific cough (a.k.a. tic cough) from those with mild or moderate to severe asthma.

METHODS

Retrospective cross sectional design. Children diagnosed with ILO (N = 70), chronic non-specific cough (N = 70), mild asthma (N = 60), or moderate to severe asthma (N = 60) were identified from the electronic medical record of a large children's hospital. Spirometry was completed before ILO, non-specific cough, or asthma diagnoses were made by pediatric laryngologists or pulmonologists. Spirometry was performed following American Thoracic Society guidelines and was interpreted by a pediatric pulmonologist. Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1), FEV1/FVC Ratio (FEV1/FVC), Forced Mid-Expiratory Flow 25--75 % (FEF25-75%), pulmonologist interpretation of flow volume loops, and overall exam findings were extracted from the medical record.

RESULTS

Ninety seven percent of children with ILO or chronic non-specific cough presented with spirometry values within normative range. Patients with ILO, non-specific cough, and mild asthma presented with FVC, FEV1, FEV1/FVC, and FEF25-75% values in statistically similar range. Children with moderate to severe asthma presented with significantly reduced FVC (p < .001), FEV1 (p < .001), FEV1/FVC (p < .001), and FEF25-75% (p < .001) values when compared with patients in the other groups. Flow volume loops were predominantly normal for children with ILO and non-specific cough.

CONCLUSIONS

Findings indicate that ILO and chronic non-specific cough can neither be diagnosed nor differentiated from mild asthma using spirometry alone. Spirometry should therefore be used judiciously with this population, bearing in mind the limitations of the procedure. Future research should determine the most effective and efficient ways of delineating ILO and non-specific cough from other respiratory conditions in children.

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.

Anxiety, Depression, and Posttraumatic Stress Disorder in Patients With Induced Laryngeal Obstruction

Importance

Patients with induced laryngeal obstruction (ILO) present with a variety of behavioral health profiles. Identifying these profiles is crucial in that behavioral health conditions may affect treatment duration and outcomes.

Objective

To characterize the prevalence of anxiety, depression, posttraumatic stress disorder (PTSD), and physical somatic symptoms in adult and pediatric patients with ILO and determine the factors associated with anxiety, depression, PTSD, and physical somatic symptoms in patients with ILO?

Design, Setting, and Participants

This cross-sectional study included a nonprobability sample of 83 adult and 81 pediatric patients diagnosed with ILO at outpatient adult and pediatric otolaryngology clinics between 2021 and 2023. Exclusion criteria included a comorbid respiratory diagnosis other than asthma, head or neck cancer, or neurological impairments. Recruitment took place between September 2021 and March 2023. The analyses were run in January 2024.

Main Outcome Measures

Patients were prospectively screened for anxiety, depression, PTSD, and somatic physical symptoms. In addition, any past behavioral health diagnoses were extracted from the medical record. Comorbidities, ILO symptoms triggers, and onset details were gathered from ILO evaluations. Adult patients completed the Screen for Adult Anxiety Related Disorders (SCAARED), depression (Patient Health Questionnaire [PHQ]-9), and somatic physical symptoms portions of the Patient Health Questionnaires (PHQ-15), and the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5). Pediatric patients completed the Screen for Child Anxiety Related Disorders (SCARED), depression (PHQ-9A) and somatic physical symptoms portions of the Patient Health Questionnaires for Adolescents (PHQ-15A), and the UCLA PTSD Reaction Index brief screeners.

Results

Eighty-three adult patients participated in this study (mean [SD] age, 45.8 [14.3] years; 64 female, 19 male). Eighty-one pediatric patients participated (mean [SD] age, 13.83 [2.55] years; 67 female, 14 male). Adult and pediatric patients with ILO screened positive for elevated rates of anxiety (53 adults [63%]; 49 children [60%]), depression (27 adults [32%]; 25 children [30%]), and PTSD (29 adults [34%]; 13 children [16%]). Most of the patients with anxiety and depression symptoms were formally diagnosed prior to ILO evaluation, with rates of previously diagnosed anxiety, depression, and PTSD also above published norms. Adults were twice as likely as children to present with PTSD (odds ratio, 2.1; 95% CI, 0.05-4.48). Elevated rates of physical somatic symptoms were also evident, with 38 adults (45%) and 32 children (39%) scoring in the moderate to severe range.

Conclusions and Relevance

This study found high rates of adult and pediatric patients with ILO screened positive for anxiety, depression, and PTSD symptoms. Future work should investigate how behavioral health and ILO treatments can best be coordinated to maximize treatment outcomes.

Medicare Restriction of Telehealth Speech Services Negatively Impacts Patient Care

OBJECTIVE

Ample literature shows voice and swallowing therapy, in-person or virtual, to be essential for Otolaryngology and Speech-Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital-based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary laryngology center.

METHODS

Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in-person, teletherapy with cash self-payment ($165-282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test.

RESULTS

Fifty-three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in-person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self-pay. 67% of patients that canceled telehealth care cited distance from in-person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P = .034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P = .007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P = .12).

CONCLUSION

Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk.

Noninvasive Management of Voice Disorders: An Umbrella Review

OBJECTIVES

The aim of this study was to assess published systematic reviews that discussed noninvasive management of voice disorders. An umbrella review was conducted to collect, organize, and summarize narratively all available pharmacologic and voice therapy interventions.

STUDY DESIGN

Umbrella review of systematic reviews.

METHODS

Pertinent systematic reviews were identified by searching Pubmed/Medline and Embase. A primary screen identified studies related to voice. The second round of screening focused on studies that involved noninvasive management of voice disorders such as pharmacologic or voice therapy interventions. Variables of interest included study design, number of studies included in the review, target population, method of intervention, and outcomes.

RESULTS

Forty-three systematic reviews were eligible and included in the umbrella review. Ten studies focused on pharmacologic interventions, and 33 studies focused on voice therapy. Individual studies included in the systematic reviews ranged from 2-47, with a total of 601 studies overall.

CONCLUSIONS

This study provides a detailed review of all available systematic reviews on noninvasive management of voice disorders. Explored medications included proton pump inhibitors, calcium channel blockers, tricyclic antidepressants, antibiotics, corticosteroids, and hormone replacement. Explored voice therapy techniques included hydration, vocal function exercises, laryngeal manual therapy, respiratory exercise, biofeedback, phonation, coping strategies, and others. This may be utilized to guide therapeutic decision-making and identify current gaps in the literature that may warrant future investigation.

Demographic Differences in Clinical Presentation of Pediatric Paradoxical Vocal Fold Motion (PVFM)

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.

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.

Economic Burden of Induced Laryngeal Obstruction in Adolescents and Children

PURPOSE

Diagnosing pediatric induced laryngeal obstruction (ILO) requires equipment typically available in specialist settings, and patients often see multiple providers before a diagnosis is determined. This study examined the financial burden associated with the diagnosis and treatment of ILO in pediatric patients with reference to socioeconomic disadvantage.

METHODS

Adolescents and children (<18 years of age) diagnosed with ILO were identified through the University of Madison Voice and Swallow Outcomes Database. Procedures, office visits, and prescribed medications were collected from the electronic medical record. Expenditures were calculated for two time periods (1) pre-diagnosis (first dyspnea-related visit to diagnosis), and (2) the first year following diagnosis. The Area Deprivation Index (ADI) was used to estimate patient socioeconomic status to determine if costs differed with neighborhood-level disadvantage.

RESULTS

A total of 113 patients met inclusion criteria (13.9 years, 79% female). Total pre-diagnosis costs of ILO averaged $6486.93 (SD = $6604.14, median = $3845.66) and post-diagnosis costs averaged $2067.69 (SD = $2322.78; median = $1384.12). Patients underwent a mean of 3.01 (SD = 1.9; median = 2) procedures and 5.8 (SD = 4.7; median = 5) office visits prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. Patients living in neighborhoods with greater socioeconomic disadvantage underwent fewer procedures and were prescribed more medication than those from more affluent areas. However, total expenditures did not differ based on ADI.

CONCLUSIONS

Pediatric ILO is associated with considerable financial costs. The source of these costs, however, differed according to socioeconomic advantage. Future work should determine how ILO diagnosis and management can be more efficient and equitable across all patients. Laryngoscope, 2024.

Examining therapy duration in adults with induced laryngeal obstruction (ILO)

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.

Computational fluid dynamics of upper airway aerodynamics for exercise-induced laryngeal obstruction: A feasibility study

Objective

Use of computational fluid dynamic (CFD) simulations to measure the changes in upper airway geometry and aerodynamics during (a) an episode of Exercise-Induced Laryngeal Obstruction (EILO) and (b) speech therapy exercises commonly employed for patients with EILO.

Methods

Magnetic resonance imaging stills of the upper airway including the nasal and oral cavities from an adult female were used to re-construct three-dimensional geometries of the upper airway. The CFD simulations were used to compute the maximum volume flow rate (l/s), pressure (Pa), airflow velocity (m/s) and area of cross-section opening in eight planes along the vocal tract, separately for inhalation and exhalation.

Results

Numerical predictions from three-dimensional geometrical modeling of the upper airway suggest that the technique of nose breathing for inhalation and pursed lip breathing for exhalation show most promising pressure conditions and cross-sectional diameters for rescue breathing exercises. Also, if EILO is due to the constriction at the vocal fold level, then a quick sniff may also be a proper rescue inhalation exercise. EILO affects both the inspiratory and the expiratory phases of breathing.

Conclusions

A prior knowledge of the supraglottal aerodynamics and the corresponding upper airway geometry from CFD analysis has the potential to assist the clinician in choosing the most effective rescue breathing technique for optimal functional outcome of speech therapy intervention in patients with EILO and in understanding the pathophysiology of EILO on a case-by-case basis with future studies.

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.

Prevalence and impact of exercise-induced laryngeal obstruction in asthma: a study protocol for a cross-sectional and longitudinal study

INTRODUCTION

Exercise-induced laryngeal obstruction (EILO) and exercise-induced asthma can cause troublesome respiratory symptoms that can be difficult to distinguish between. Further, there is now a growing appreciation that the two conditions may coexist, complicating the interpretation of symptoms. The primary aim of this study is to investigate the prevalence of EILO in patients with asthma. Secondary aims include evaluation of EILO treatment effects and investigation of comorbid conditions other than EILO in patients with asthma.

METHODS AND ANALYSIS

The study will be conducted at Haukeland University Hospital and Voss Hospital in Western Norway, and enrol 80-120 patients with asthma and a control group of 40 patients without asthma. Recruitment started in November 2020, and data sampling will continue until March 2024. Laryngeal function will be assessed at baseline and at a 1-year follow-up, using continuous laryngoscopy during high-intensity exercise (CLE). Immediately after the EILO diagnosis is verified, patients will be treated with standardised breathing advice guided by visual biofeedback from the laryngoscope video screen. The primary outcome will be the prevalence of EILO in patients with asthma and control participants. Secondary outcomes include changes in CLE scores, asthma-related quality of life, asthma control and number of the asthma exacerbations, as assessed between baseline and the 1-year follow-up.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Regional Committee for Medical and Health Research Ethics, Western Norway, (ID number 97615). All participants will provide signed informed consent before enrolment. The results will be presented in international journals and conferences.

TRIAL REGISTRATION NUMBER

NCT04593394.

Multi-Institutional Study of Patient-Reported Outcomes of Paradoxical Vocal Fold Motion

OBJECTIVE

To explore patient-reported outcome measures of pediatric paradoxical vocal fold motion through a multi-institutional study of geographically diverse United States medical facilities to assess long-term management and outcomes.

METHODS

Eligible participants >8 years of age diagnosed with PVFM over a 10-year period from 7 tertiary pediatric hospitals were invited to complete a survey addressing study objectives.

RESULTS

65 participants completed the survey, of whom 80% were female, 75% reported a 3.5 grade point average or better, and 75% identified as competitive athletes or extremely athletic individuals. Participants rated their perceived efficacy of 13 specific treatments. Only five treatments were considered effective by a majority of the participants who tried them. The treatments that participants tried most often were breathing exercises (89.2%), bronchodilator treatments (45%), and allergy medications (35.4%). 78.8% of participants reported receiving more than one treatment and 25% reported receiving a combination of bronchodilators, anticholinergics, and steroids. At the time of PVFM diagnosis, 38% of participants had no idea when their symptoms would completely resolve. 23.3% of participants did not experience symptom resolution until greater than 1 year after diagnosis.

CONCLUSIONS

Traditional management tools such as breathing exercises and biofeedback treatments may not provide the long-term benefit that providers anticipate. In addition to these commonly used management strategies, highly efficacious techniques such as counseling and lifestyle management should be incorporated into the long-term management of patients whose symptoms are refractory to traditional care.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:970-976, 2023.

Examining the Influence of Chemosensation on Laryngeal Health and Disorders

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.

Identification of Breathing Pattern Disorder in Athletes With Exercise-Induced Laryngeal Obstruction: A Novel Assessment Tool

OBJECTIVE

To report the diagnostic utility of the novel, high-ventilatory task assessment tool called the Milstein Breathing Pattern Assessment Index (M-BPAI) for evaluation of Breathing Pattern Disorder (BPD) in athletes with and without breathing difficulty, and to evaluate the prevalence of BPD in athletes referred for Exercise Induced Laryngeal Obstruction (EILO). BPD is an abnormal respiratory biomechanical pattern caused from functional or structural factors. The presence of BPD in athletes with EILO is unknown. The current clinical evaluations of dysfunctional breathing patterns are limiting for evaluation of BPD in patients with EILO, as these only evaluate the patients in low ventilatory output tasks of rest breathing.

STUDY DESIGN AND METHODS

In this prospective study, a total of 77 athletes referred to the clinic for suspected EILO and 58 athletes without any respiratory difficulty underwent M-BPAI assessment. Data collection from the experimental group also included the Dyspnea Index, and laryngeal video endoscopic provocation test.

RESULTS

The M-BPAI score was significantly larger in the patient group compared to the control group. An overall M-BPAI score of ≥8 corresponds to the AUC of 0.87 (95% CI: 0.81-0.93) with a sensitivity of 0.862 and specificity of 0.792. A total of 60 (78%) patients had an overall M-BPAI score of ≥8.

CONCLUSION

The M-BPAI has the potential to be a valuable clinical diagnostic marker for identifying BPD in patients with suspected EILO with further research and validation.

Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics

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.

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.

Systematic review of the effectiveness of non-pharmacological interventions used to treat adults with inducible laryngeal obstruction

Introduction

Inducible laryngeal obstruction (ILO) describes transient laryngeal closure during respiration and can cause significant morbidity. Non-pharmacological behavioural therapy is the commonly cited treatment but efficacy is largely unknown.

Aim

To synthesise the current evidence base on the effectiveness of non-pharmacological interventions used to treat adults with ILO.

Methods

Electronic databases (Medline/Embase/CINAHL/PsycINFO/AMED/CENTRAL) were systematically searched, informed by a population, intervention, comparison, outcome framework. Two reviewers independently screened a representative sample, with lead-author completion due to excellent inter-rater reliability. Data was extracted using a predefined piloted form. Methodological quality was appraised (blindly by two reviewers) using the Joanna Briggs Institute Critical Appraisal Tools. A narrative synthesis was performed due to heterogeneity of studies (PROSPERO registration number: CRD42020213187).

Results

Initial searching identified 3359 records. Full-text screening occurred in 92 records and 14 studies, comprising 527 participants, were deemed eligible. All studies were low-level evidence (observational by design, with four case reports), with a high risk of bias; none contained control arms for comparison. Intervention description was inconsistently and poorly described but direction of effect was positive in 76% of outcomes measured. The majority of studies showed a reduction in symptom scores and improved direct laryngeal imaging post intervention; there was an overall reduction, 59.5%, in healthcare utilisation.

Discussion

The literature is in an embryonic state and lacks robust data to truly inform on the effectiveness of non-pharmacological interventions used to treat adults with ILO. However, positive signals in the synthesis performed support non-pharmacological treatment approaches and further development is warranted.

Die induzierbare laryngeale Obstruktion (ILO) – Ursachen, klinische Präsentation, Diagnostik und Therapie

Wiederholt 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.

Treatment effectiveness for Vocal Cord Dysfunction in adults and adolescents: A systematic review

OBJECTIVE

To determine whether treatment effectiveness can be established for a range of vocal cord dysfunction (VCD) interventions in adolescents and adults.

DESIGN

A systematic review of the literature and risk of bias appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools. Data were qualitatively synthesized in the broad intervention groups of glottic airway and respiratory retraining, pharmacological therapies, airway device therapies and psychological therapies.

DATA SOURCES

Nine electronic databases, two clinical trial registries and the grey literature were searched from inception to September 2021 for articles on VCD interventions or equivalent terms.

ELIGIBILITY CRITERIA

Studies were included if they were randomized controlled trials, non-randomized controlled trials, quasi-experimental pre- and post-test studies and within-subject repeated measure designs, participants were 13 years or older, VCD was diagnosed using laryngoscopy or CT larynx, VCD intervention was provided and outcome measures reported on VCD symptoms.

RESULTS

The search yielded no randomized controlled trials. There were 17 quasi-experimental studies that met the eligibility criteria, and these studies reported on glottic airway and respiratory retraining, botulinum toxin injections, inspiratory muscle strength training and amitriptyline; all were associated with VCD symptom reduction. In addition, 2 within-subject repeated measure studies reported inspiratory muscle strength training and respiratory retraining to be effective in reducing symptoms in participants with exertional VCD. The included studies were reported in full-text publications (11) and conference proceedings (8). There was a high risk of bias and low quality of evidence across all intervention areas.

CONCLUSION

Glottic airway and respiratory retraining, botulinum toxin injections, low-dose amitriptyline and inspiratory muscle strength training devices have been associated with symptom reduction in adults and adolescents with vocal cord dysfunction. Limited objective data exist to support the effectiveness of these interventions, and robust controlled trials are needed in this area. Systematic Review Registration: CRD42018092274 (PROSPERO).

Economic Burden Associated With Management of Paradoxical Vocal Fold Motion Disorder

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.

Visual biofeedback for paradoxical vocal fold motion (PVFM)

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

Struggling to Breathe: Inspiratory Muscle Training in Adolescent Athletes

OBJECTIVE

Dyspnea is a primary characteristic of exercise-induced laryngeal obstruction and prevents individuals from inhaling and exhaling without effort. This single subject research study investigated the effects of inspiratory muscle training (IMT) on exercise-induced symptoms characteristic of exercise-induced laryngeal obstruction in adolescent athletes.

METHODS

Five weeks of IMT was provided to five adolescent athletes, four females and one male, aged 10 to 16. Variables that were measured prior to, during, and after completion of IMT program included maximum phonation time, maximum perceived breathlessness, duration of running, and quality of life regarding dyspnea.

RESULTS

Results showed a reduction in maximum perceived breathlessness as well as a significant increase in maximum phonation time across participants. The majority of participants rated their quality of life regarding dyspnea as significant improved after IMT.

CONCLUSIONS

These findings contribute to the increasing body of literature investigating the use of alternative therapy strategies for treatment of symptoms of exercise-induced laryngeal obstruction in adolescent athletes.

Outcomes of Paradoxical Vocal Cord Motion Diagnosed in Childhood

OBJECTIVES

To explore long-term patient reported outcome (PRO) measures of pediatric paradoxical vocal cord motion (PVCM) including ease of diagnosis, management, symptom duration and effect on quality of life.

METHODS

All children >8 years of age diagnosed with PVCM at a tertiary pediatric hospital between 2006 and 2017 were invited to complete a survey addressing study objectives.

RESULTS

21/47 eligible participants could be contacted and 18/21 (86%) participated. 78% were female with a mean age at diagnosis of 11.6 and 15.0 years at survey completion. Common PVCM symptoms reported were dyspnea (89%), globus sensation (56%), and stridor (50%). The median time to diagnosis was 3 months (IQR 2-5 months). Nearly all reported being misdiagnosed with another condition, usually asthma, until being correctly diagnosed usually by an otolaryngologist. Participants reported undergoing 3.7 diagnostic studies (range 0-8); pulmonary function testing was most common. Of numerous treatments acknowledged, breathing exercises were common (89%) but only reported helpful by 56%. Use of biofeedback was recalled in 1/3 of subjects but reported helpful in only 14% of them. Anti-reflux, allergy, anticholinergics, inhalers and steroids were each used in >50%, but rarely reported effective. PVCM was reportedly a significant stressor when initially diagnosed but despite 2/3 of participants still reporting ongoing PVCM symptoms, the perceived stress significantly decreased over time (Z = 3.26, P = 0.001).

CONCLUSIONS

This first PVCM PRO study endorses that diagnosis is often delayed and prescribed treatments often viewed as ineffective. While biofeedback and breathing exercises may be critical for short-term control of PVCM episodes, lifestyle changes and stress reduction are likely necessary for long-term management. Increased awareness and improvements in management are needed for this condition.

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.

Upper Airway Pathology Contributes to Respiratory Symptoms in Children Born Very Preterm

OBJECTIVE

To evaluate the role of upper airway dysfunction, indicated by altered vocal quality (dysphonia), on the respiratory symptoms of children surviving very preterm birth.

STUDY DESIGN

Children born <32 weeks of gestation participated in 2 separate assessments during midchildhood. The first visit assessed voice quality by a subjective evaluation using the Consensus Auditory-Perceptual Evaluation of Voice and a computerized analysis of the properties of the voice via the Acoustic Voice Quality Index. The second assessment recorded parentally reported respiratory symptoms and measures of lung function, including spirometry, lung volumes, oscillatory mechanics, and a cardiopulmonary exercise test.

RESULTS

Preterm children (n = 35; median gestation 24.3 weeks) underwent paired voice and lung assessments at approximately 11 years of age. Preterm children with dysphonia (n = 25) reported significantly more respiratory symptoms than those with normal voices (n = 10) including wheeze (92% vs 40%; P = .001) and asthma diagnosed by a physician (60% vs 10%; P = .007). Lung function outcomes were generally not different between the dysphonic group and the group with normal voice (P > .05), except for the oscillatory mechanics measures, which were all at least 0.5 z score lower in the dysphonic group (Xrs₈ mean difference = -0.91 z scores, P = .003; f_res = 1.06 z scores, P = .019; AX = -0.87 z scores, P = .010; Rrs₈ = 0.63 z scores, P = .068).

CONCLUSIONS

The upper airway may play a role in the respiratory symptoms experienced by some very preterm children and should be considered by clinicians, especially when symptoms are in the presence of normal lung function and are refractory to treatment.

Vocal Cord Dysfunction: The Spectrum Across the Ages

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.

Buteyko Breathing Technique for Exertion-Induced Paradoxical Vocal Fold Motion (EI-PVFM)

PURPOSE

The primary purpose of the current study was to determine the usefulness of Buteyko breathing technique (BBT) in reducing dyspnea in patients with one form of Paradoxical Vocal Fold Motion (PVFM), exertion-induced PVFM (EI-PVFM), concomitant with hyperventilation. The secondary purpose was to determine whether BBT had an effect on physiological markers of hyperventilation, as speculated by BBT theory: respiratory tidal minute volume (RTMV), end-tidal carbon dioxide (ETCO₂), and resting heart rate (HR).

METHODS

Using a within-subjects, repeated measures group design, 12 participants with EI-PVFM and hyperventilation underwent 12 weeks of BBT, following an initial no-treatment control condition. Outcome measures of PVFM-dyspnea frequency and severity-and of hyperventilation-HR, RTMV, and ETCO₂-were acquired pre- and post-treatment.

RESULTS

Results showed post-treatment decreases in dyspnea severity, HR, and RTMV, as well as increases in ETCO₂. Decreases in dyspnea and RTMV measures remained after correction for alpha inflation.

CONCLUSIONS

Findings suggest BBT may be useful for some individuals with EI-PVFM and hyperventilation. The high prevalence of hyperventilation in EI-PVFM found in the current study warrants further investigation.

Short-Term Intensive Therapy and Outcomes for Athletes With Paradoxical Vocal Fold Motion Disorder

Purpose The aim of the study was to develop a treatment for athletes with paradoxical vocal fold motion disorder (PVFMD) based on exercise physiology and learning theory principles and administer it over a preestablished time frame. Method A prospective, repeated-measures, within-subject group design was used. Eleven adolescent/teen athletes diagnosed with PVFMD via laryngoscopy received short-term intensive (STI) therapy. Eight of the athletes returned for extended follow-up. Changes in postexercise inspiratory ( R _i) and expiratory ( R _e) resistances and Modified Borg Dyspnea Scale (MBDS) ratings collected at baseline were compared immediately posttreatment and at extended follow-up. Dyspnea Index scores were collected at baseline and at extended follow-up. Two no-treatment control athletes with PVFMD participated in two exercise challenges-baseline and 6 weeks later. Results Immediately after STI therapy, athletes attained significant improvement in R _i, R _e, and MBDS ratings. These changes were maintained at extended follow-up as well as a significant change in Dyspnea Index scores. The 2 control athletes who were reassessed 6 weeks after baseline experienced negative changes in postexercise R _i and MBDS ratings. Conclusion STI therapy that incorporated individuality, specificity, and variable practice effectively changed outcome measures posttreatment with further improvement observed at extended follow-up. These results provide preliminary evidence for STI therapy for PVFMD.

Physiotherapy improves symptoms of exercise-induced laryngeal obstruction in young elite athletes: a case series

OBJECTIVE

A constricted, upper chest breathing pattern and postural dealignments habitually accompany exercise-induced laryngeal obstruction (EILO), but there are few effective treatments for athletes presenting with EILO. This case series was conducted to examine whether physiotherapy based on principles from the Norwegian psychomotor physiotherapy (NPMP) combined with elements of cognitive behavioural therapy can reduce laryngeal distress in athletes with EILO.

METHODS

Respiratory distress in four subjects was examined by interview prior to a physiotherapeutic body examination. Inappropriate laryngeal movements during exercise were measured by the continuous laryngoscopy exercise test, lung function was measured by flow-volume curves, and non-specific bronchial hyper-responsiveness was measured by a methacholine provocation test. History of asthma, allergy and respiratory symptoms was recorded in a modified AQUA2008 questionnaire. Parasympathetic activity was assessed by pupillometry. All data were gathered before and after 5 months of intervention.

RESULTS

Physiotherapy based on the principles from NPMP improved breathing problems in athletes with EILO. All athletes had less respiratory distress, improved lung function at rest and reduced inappropriate laryngeal movements during maximal exercise.

CONCLUSION

A diaphragmatic breathing pattern, a more balanced tension in respiratory muscles, and sound cervical alignment and stability may help to reduce adverse stress on the respiratory system and optimise the function of the larynx during high-intensity exercise. Our results suggest that understanding and management of EILO need to extend beyond structures located in the anterior neck and include factors influencing the whole respiratory system.

Factors Affecting Initiation of Voice Therapy for Paradoxical Vocal Fold Motion Disorder

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.

Hemi-laryngopharyngeal spasm as a novel cause of inducible laryngeal obstruction with a surgical cure: report of 3 cases

Inducible laryngeal obstruction has been described under at least 40 different monikers, including vocal cord dysfunction, paroxysmal vocal fold motion, and irritable larynx. The etiology of this condition is believed to be laryngeal hyperactivity in response to psychological issues or acid reflux. Most patients are treated with some combination of proton pump inhibitors, speech therapy, and psychotherapy. However, a small cohort of patients remains refractory to all medical interventions. The authors describe a novel condition, hemi-laryngopharyngeal spasm (HELPS), which can cause severe episodic stridor leading to unconsciousness in association with cough. The first recognized and surgically cured patient with HELPS was reported in an earlier issue of this journal. Three additional patients have been followed up for at least a year postoperatively, and their cases are reported here.Each patient presented with a similar pattern of episodic coughing and choking that increased in frequency, severity, and duration over years. The episodes eventually occurred while sleeping and could cause severe stridor with loss of consciousness. All three patients were initially misdiagnosed with a psychiatric illness and subjected to multiple intubations and one tracheostomy. Unilateral botulinum toxin injections in the vocal fold eased the severity of the throat contractions but not the cough. Magnetic resonance imaging showed a looping posterior inferior cerebellar artery juxtaposed to a vagus nerve in each case. Microvascular decompression (MVD) of that vessel relieved all symptoms.The introduction of this new medical condition may help a small cohort of patients with inducible laryngeal obstructions that have not responded to the current standard treatments. Patients are asymptomatic between episodes of progressively severe coughing and choking with stridor that may lead to intubation. Severe anxiety about the unpredictable symptoms is expected and may contribute to a psychiatric misdiagnosis. Microvascular decompression for HELPS is more difficult than that for trigeminal neuralgia because the involved nerve is more susceptible to manipulation. Ultimately, the final proof that HELPS is a real and distinct syndrome will require its recognition and successful treatment by colleagues around the world.

Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation

The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.

Observational study of laryngoscopy plus flow-volume loops during exercise

Laryngoscopy is the gold standard to diagnose exercise‐induced laryngeal obstruction, though inspiratory flow‐volume loop may provide a clue. We combined tidal flow‐volume loop analysis plus laryngoscopy during exercise and found that cigar‐shaped – not flattened – inspiratory loops are associated with obstruction. Pursed‐lip breathing slows inhalation thereby reducing vocal fold adduction.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Objective

This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.

Purpose

The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.

Action Statements

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.

Disclaimer

This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia

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.

Increased respiratory neural drive and work of breathing in exercise-induced laryngeal obstruction

Exercise-induced laryngeal obstruction (EILO), a phenomenon in which the larynx closes inappropriately during physical activity, is a prevalent cause of exertional dyspnea in young individuals. The physiological ventilatory impact of EILO and its relationship to dyspnea are poorly understood. The objective of this study was to evaluate exercise-related changes in laryngeal aperture on ventilation, pulmonary mechanics, and respiratory neural drive. We prospectively evaluated 12 subjects (6 with EILO and 6 healthy age- and gender-matched controls). Subjects underwent baseline spirometry and a symptom-limited incremental exercise test with simultaneous and synchronized recording of endoscopic video and gastric, esophageal, and transdiaphragmatic pressures, diaphragm electromyography, and respiratory airflow. The EILO and control groups had similar peak work rates and minute ventilation (V̇e) (work rate: 227 ± 35 vs. 237 ± 35 W; V̇e: 103 ± 20 vs. 98 ± 23 l/min; P > 0.05). At submaximal work rates (140-240 W), subjects with EILO demonstrated increased work of breathing ( P < 0.05) and respiratory neural drive ( P < 0.05), developing in close temporal association with onset of endoscopic evidence of laryngeal closure ( P < 0.05). Unexpectedly, a ventilatory increase ( P < 0.05), driven by augmented tidal volume ( P < 0.05), was seen in subjects with EILO before the onset of laryngeal closure; there were however no differences in dyspnea intensity between groups. Using simultaneous measurements of respiratory mechanics and diaphragm electromyography with endoscopic video, we demonstrate, for the first time, increased work of breathing and respiratory neural drive in association with the development of EILO. Future detailed investigations are now needed to understand the role of upper airway closure in causing exertional dyspnea and exercise limitation. NEW & NOTEWORTHY Exercise-induced laryngeal obstruction is a prevalent cause of exertional dyspnea in young individuals; yet, how laryngeal closure affects breathing is unknown. In this study we synchronized endoscopic video with respiratory physiological measurements, thus providing the first detailed commensurate assessment of respiratory mechanics and neural drive in relation to laryngeal closure. Laryngeal closure was associated with increased work of breathing and respiratory neural drive preceded by an augmented tidal volume and a rise in minute ventilation.

Paradoxical vocal fold motion (PVFM) in pediatric otolaryngology

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.

Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction)

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.

Muscle Tension Dysphagia

Objective

To identify symptoms, common diagnostic findings, pattern of treatments and referrals offered, and their efficacy in a group of patients with idiopathic functional dysphagia in an otolaryngology setting with multiple providers.

Study Design

Case series with chart review.

Setting

Tertiary academic center.

Subjects and Methods

Following Mayo Clinic Institutional Review Board approval, a retrospective chart review was conducted of patients with dysphagia who had a videofluoroscopic swallow study between January 1, 2013, and April 30, 2015. Each patient’s dysphagia symptomology, videofluoroscopic swallow study, flexible laryngoscopy, and medical chart were reviewed to identify the treatment paradigms that were utilized.

Results

Sixty-seven adult patients met the inclusion criteria. Abnormal laryngeal muscle tension was present in 97% of patients. Eighty-two percent of patients also demonstrated signs of laryngeal hyperresponsiveness. Nonspecific laryngeal inflammation was evident in 52% of patients. Twenty-seven patients were referred to speech-language pathology for evaluation. Thirteen patients completed a course of voice therapy directed toward unloading muscle tension. All 13 patients self-reported resolution of dysphagia symptoms.

Conclusion

The study results suggest that laryngeal muscle tension may be a factor in the underlying etiology in patients with idiopathic functional dysphagia. We propose the diagnostic term muscle tension dysphagia to describe a subset of patients with functional dysphagia. Further prospective studies are needed to better evaluate potential gastroesophageal confounders in this group of patients and to identify an effective paradigm for treatment. In our limited series, speech-language pathology intervention directed toward unloading muscle tension appears effective.