Pediatric paradoxical vocal-fold motion: presentation and natural history

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, 134:3384-3390, 2024.

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.

All That Wheezes Is Not Asthma

Wheezing is a high pitched, whistling sound generated when air flows through narrowed airways and is often equated with asthma. However, wheezing may be a presenting symptom of various other conditions including structural lesions of the airways, foreign body aspiration, pulmonary infections as well as cardiac causes. Underlying etiology of wheezing may also vary with age. Detailed history, physical examination, and laboratory investigations are often required to identify the underlying etiology of wheezing. Additional studies may sometimes be needed to accurately identify the underlying etiology such as pulmonary function test or spirometry, chest radiography (chest X-ray), and bronchoscopy. This review article discusses the common causes of wheezing encountered in clinical practice. [Pediatr Ann. 2024;53(5):e189-e194.].

Potential Risks for Healthcare Disparities Among Individuals With Voice and Upper Airway Disorders: A Systematic Review

PURPOSE

To assess the potential epidemiological association between various possible risk factors and healthcare disparities specifically related to the access, use and/or quality of speech language pathology services for individuals with voice and upper airway disorders.

METHOD

A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis. Full text journal articles were identified through PubMed, PsycINFO and Web of Science. The reference sections of included articles were also manually screened and identified four additional studies for consideration of inclusion. Included articles specifically addressed healthcare disparities in voice and upper airway disorders related to speech pathology care. International literature was excluded. Eligible studies were reviewed and data extracted. Risk of bias of each eligible study was performed using the quality assessment tool from National Institute of Health for observational cohort and cross-sectional studies. Data from eligible studies were synthesized thematically.

RESULTS

A total of 1,101 resources were retrieved from the search; of these, 133 were duplicates. Titles and abstracts of 968 articles were screened, with 14 selected for full-text review. Eleven articles were considered eligible for inclusion. Voice disorders were the condition most frequently examined followed by only one article addressing upper airways disorders. There was considerable heterogeneity in the methodology and statistical analyses among the eligible papers. There was a lack of standard methodology for collecting and accurately determining patient characteristics as well as variability in measuring confounding variables and providing statistical analyses for such adjustments that may have impacted the findings. The information extracted from these articles revealed healthcare disparities related to sex/gender, age, insurance status/coverage, race/ethnicity, among others including etiology and preferred language.

CONCLUSIONS

This systematic review highlights the limited research on speech language pathology-specific healthcare disparities for individuals with voice and upper airway disorders. There was significant clinical and methodological heterogeneity between studies which may have contributed to varied results between studies. There is a need for greater methodological rigor and prospectively designed studies to better characterize the impact of disparities in the access to, use of, and quality of speech pathology care for this patient population.

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

OBJECTIVE

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

STUDY DESIGNS

Retrospective review.

SETTING

Multidisciplinary PVFM hospital clinic.

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4.

Bilateral Vocal Cord Paralysis Requiring Long-term Tracheostomy After SARS-CoV-2 Infection

Bilateral vocal cord paralysis can cause obstruction of glottic airflow, resulting in respiratory distress and the need for a surgical airway. We report a case of acute onset bilateral vocal cord paralysis in a healthy adolescent patient 9 days after a mild severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This 15-year-old patient presented with dyspnea, tachypnea, and stridor. A fiberoptic laryngoscopy revealed bilateral vocal fold paralysis with limited vocal cord abduction causing respiratory distress. A detailed set of diagnostic test results, including blood work, imaging, and a lumbar puncture, were all negative other than her new onset diagnosis of SARS-CoV-2 infection. The patient underwent tracheostomy placement with the subsequent resolution of her symptoms. Her vocal cord function remains impaired, and the patient continues to be tracheostomy-dependent 13 months after the initial presentation. SARS-CoV-2 infection has multiple well-established neurologic complications in children. The current case suggests that vocal cord paralysis may be an additional neuropathic sequela of the virus. Vocal cord pathology should be an important consideration when constructing a differential for children presenting with voice, swallowing, or breathing complaints after SARS-CoV-2 infection.

Management of comorbidities in difficult and severe asthma

Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.

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.

Predictors of voice therapy efficacy in vocal cord dysfunction at a tertiary care center

OBJECTIVE

Vocal cord dysfunction is inappropriate adduction of vocal cords during inspiration that causes dyspnea and is commonly mistaken for exercise-induced asthma. To improve diagnostic accuracy, this study aims to identify demographics associated with vocal cord dysfunction and to determine their impact on the efficacy of voice therapy in improving vocal cord function.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care institution between January 2015 and December 2021.

METHODS

184 patients who underwent voice therapy for vocal cord dysfunction were included. The primary outcome was patient self-reported percent improvement of symptoms. The secondary outcome was number of voice therapy treatments.

RESULTS

The mean duration of symptoms was 2 ± 3 years. The mean number of voice therapy treatments was 2.2 ± 1.5. Of the 107 (58.2 %) patients with documented perceived breathing improvement percentages recorded, the mean maximal percent improvement was 72.5 ± 21.5 %. Mean maximal percent improvement of symptoms increased with each voice therapy treatment (p = 0.01). This association remained significant when controlling for comorbid conditions such as allergic rhinitis with postnasal drip, anxiety, asthma, and gastroesophageal reflux disease in multivariate analysis (p = 0.005). Patients with asthma had significantly higher maximum percent breathing improvement compared to those without asthma (p = 0.026). Similarly, patients who played sports had significantly higher maximum percent breathing improvement compared to those who did not (p = 0.022).

CONCLUSION

Patient perceived breathing improvement with voice therapy is higher among those with concomitant asthma and those who play sports. Voice therapy is a safe and effective first line treatment of vocal cord dysfunction even when controlling for comorbid conditions.

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.

Diagnostic work-up of exercise-induced laryngeal obstruction

PURPOSE

Exercise-induced laryngeal obstruction (EILO) is suspected when dyspnea associated with upper airway symptoms is triggered by exercise. This condition affects mainly adolescent athletes. Visualization of the obstruction, while the patient is experiencing the symptoms during continuous laryngoscopy during exercise (CLE-test) is the gold standard for diagnosing EILO. Our study aims to evaluate the prevalence of EILO in a population presenting exercise-induced inspiratory symptoms (EIIS) or uncontrolled asthma with exertional symptoms. The second objective was to evaluate the diagnostic strength of laryngology consultation (LC) and pulmonary function tests (PFTs).

METHODS

All patients referred to our center for EIIS or uncontrolled asthma with exertional symptoms were included. EILO diagnosis was made if Maat score was > 2 for patients with CLE-test or if there were inspiratory anomalies on PFTs and LC. The sensitivity and specificity of LC and PFTs as diagnostic tools were calculated considering CLE-test as the gold standard.

RESULTS

Sixty two patients were referred to our center for EIIS or uncontrolled asthma with exertional symptoms. EILO was diagnosed in 28 patients (56%) with associated asthma in 9 patients (18%). The sensibility and specificity of LC for supraglottic anomalies were 75% and 60%, respectively. The sensibility and specificity of PFTs were 61% and 89%, respectively.

CONCLUSIONS

There was a high prevalence of EILO among patients with EIIS and uncontrolled asthma. Some clinical characteristics might guide the diagnosis. Nevertheless, CLE-test remained the gold standard for EILO diagnosis and identification of the dysfunctional upper airway site to provide specific management.

The impact of a fast-track questionnaire in pediatric paradoxical vocal fold motion disorder (PVFMD)

OBJECTIVE

PVFMD is a frequent cause of dyspnea in the healthy adolescent. When PVFMD is suspected, the current standard of care includes referral to an otolaryngologist (ENT) prior to beginning laryngeal control therapy (LCT) with a speech language pathologist (SLP). We hypothesize that a "fast-track" screening questionnaire will improve time to treatment and decrease patient charges.

METHODS

Patients (n = 258, group 1) who received traditional referral and were evaluated in pediatric voice clinic with a diagnosis of PVFMD between 11/2013 and 11/2017 were identified and compared with 66 patients (group 2) from 10/2018 to 11/2019 who were prospectively studied and placed into a fast-tracked subgroup for LCT without preceding ENT evaluation if they scored 8/10 or higher on a designed screening questionnaire.

RESULTS

Female gender (group 1: 81%, group 2: 83%, p = 0.73) and median age (group 1:14 years IQR 4; group 2:14 years IQR 3, p = 0.83) were similar. The median duration from symptom onset to LCT was shorter for group 2 (group 1: 12 months, IQR 18; group 2: 8.5 months, IQR 8)(p = 0.02). Time from referral to LCT was shorter for group 2 at 3 weeks (IQR 3) compared to group 1 at 4 weeks (IQR 3.5, p < 0.01). The minimum single patient charge for group 1 was estimated at $5123 and $1649 for group 2, yielding a potential reduction of charges of over $3000.

CONCLUSION

Using a fast-track screening questionnaire for pediatric PVFMD patients significantly decreases the time to treatment without altering the response rate of LCT.

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.

Conundrums in the breathless athlete; exercise induced laryngeal obstruction or asthma?

PURPOSE

Exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) are two disorders commonly considered when athletes complain of exertional dyspnea. They are highly different but often confused. We aimed to address this diagnostic challenge and its consequences in elite athletes.

METHODS

We included all athletes competing at national or international level, referred to our institution for workup for EILO during 2013-2016. We diagnosed EILO from video-recorded laryngoscopy performed during maximal cardiopulmonary treadmill exercise (CLE-test). Symptoms and previous diagnostic evaluations were obtained from referral letters and chart reviews.

RESULTS

EILO was diagnosed in 73/101 referred athletes, of whom 70/73 had moderate/severe supraglottic obstruction and 3/73 had primarily glottic obstruction with only minor supraglottic involvement. Of the 73 athletes with EILO, we were able to identify objective tests for asthma in 55 participants, of whom 22 had findings supporting asthma. However, 58/73 had used asthma therapy at some time previously, with current use in 28. Only three reported that asthma medication had improved their exercise related breathing problems, two of whom with tests confirming asthma. Treatment for EILO improved breathing problems in all but four.

CONCLUSIONS

Objective testing verified EILO in most of the referred athletes. EILO coexisting with asthma was common, and large proportions had used asthma medication; however, few reported effect on exercise related breathing problems. Unexplained persistent exertional dyspnoea must not lead to indiscriminate escalation of asthma treatment, but instead incite investigation for EILO, either as a co-morbidity or as a differential diagnosis.

Do not forget asthma comorbidities in pediatric severe asthma!

Asthma is the most common chronic respiratory disease in childhood. The long-term goals in managing asthma aim to control symptoms and prevent exacerbations, as well as to reduce side effects of therapy and mortality disease-related. Most of patients have mild to moderate asthma and respond well to standard therapies. However, a minor proportion of children with asthma has severe disease that remains uncontrolled despite optimal adherence to prescribed therapy and treatment of contributory factors, including trigger exposures and comorbidities, which can mimic or worsen asthma and contribute to exacerbations and poor quality of life. Evaluation of comorbidities is fundamental to optimize the management of the disease in a subgroup of patients with poor responder asthma. The overall aim of this article is to describe characteristics of main pediatric severe asthma comorbidities reported in literature, giving clinicians tools to recognize and manage properly these conditions.

Exercise-induced Laryngeal Obstruction: Protocol for a Randomized Controlled Treatment Trial

BACKGROUND

Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, caused by paradoxical inspiratory adduction of laryngeal structures, and diagnosed by continuous visualization of the larynx during high-intensity exercise. Empirical data suggest that EILO consists of different subtypes, possibly requiring different therapeutic approaches. Currently applied treatments do not rest on randomized controlled trials, and international guidelines based on good evidence can therefore not be established. This study aims to provide evidence-based information on treatment schemes commonly applied in patients with EILO.

METHODS AND ANALYSIS

Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital will be randomized into four non-invasive treatment arms, based on promising reports from non-randomized studies: (A) standardized information and breathing advice only (IBA), (B) IBA plus inspiratory muscle training, (C) IBA plus speech therapy, and (D) IBA plus inspiratory muscle training and speech therapy. Differential effects in predefined EILO subtypes will be addressed. Patients failing the non-invasive approach and otherwise qualifying for surgical treatment by current department policy will be considered for randomization into (E) standard or (F) minimally invasive laser supraglottoplasty or (G) no surgery. Power calculations are based on the main outcomes, laryngeal adduction during peak exercise, rated by a validated scoring system before and after the interventions.

ETHICS AND DISSEMINATION

The study will assess approaches to EILO treatments that despite widespread use, are insufficiently tested in structured, verifiable, randomized, controlled studies, and is therefore considered ethically sound. The study will provide knowledge listed as a priority in a recent statement issued by the European Respiratory Society, requested by clinicians and researchers engaged in this area, and relevant to 5-7% of young people. Dissemination will occur in peer-reviewed journals, at relevant media platforms and conferences, and by engaging with patient organizations and the healthcare bureaucracy.

Management/Comorbidities of School-Aged Children with Asthma

Asthma is a complex heterogeneous disease characterized by reversible airflow obstruction. After appropriate diagnosis, the management in school-aged children centers on 3 broad domains: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers. It is important to understand that the phenotypic differences that exist in the school-aged child with asthma may impact underlying comorbid conditions as well as pharmacologic treatment choices. Following initiation of therapy, asthma control must be continually evaluated in order to optimize management.

A unique presentation and etiology of neonatal paradoxical vocal fold motion

We present a unique case of intermittent paradoxical vocal fold motion (PVFM) as the presenting symptom of a rare underlying neuromuscular disorder in a neonate. Paramyotonia congenita (PC) is an autosomal dominant condition that typically presents in infancy with myotonic episodes affecting the skeletal muscles. Our patient developed intermittent episodes of stridor quickly progressing to apnea shortly after birth that were marked by PVFM on laryngoscopy, ultimately leading to the diagnosis of a previously unrecognized mutation in SCN4A, the gene responsible for PC.

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.

Confounders of severe asthma: diagnoses to consider when asthma symptoms persist despite optimal therapy

Asthma can often be challenging to diagnose especially when patients present with atypical symptoms. Therefore, it is important to have a broad differential diagnosis for asthma to ensure that other conditions are not missed. Clinicians must maintain a high index of suspicion for asthma mimickers, especially when patients fail to respond to conventional therapy. The purpose of this review is to briefly review some of the more common causes of asthma mimickers that clinicians should consider when the diagnosis of asthma is unclear.

Diagnosis and treatment of paradoxical vocal fold motion in infants

IMPORTANCE

Paradoxical vocal fold motion (PVFM) is a disorder often misdiagnosed in children presenting with shortness of breath and stridor. In infants, little is known about the clinical course and best approach for treatment of PVFM. This retrospective study assesses the approach to treatment and outcomes for infants with PVFM.

OBJECTIVE

To investigate the clinical course of paradoxical vocal fold motion (PVFM) in infants.

DESIGN

Retrospective review.

SETTING

Tertiary academic medical center.

PARTICIPANTS

Patients less than 2 years of age diagnosed with PVFM were identified and included in the study.

MAIN OUTCOMES AND MEASURES

History, physical exam findings, and clinical course of treatment for patients less than 2 years old with PVFM were reviewed. Findings including those on flexible fiberoptic laryngoscopy (FFL) and subjective assessment by parents and clinicians were compiled for review.

RESULTS

Seven infants were diagnosed with PVFM. All patients were full term at birth, and average age at diagnosis was 7 months. All patients initially presented with inspiratory stridor, and two patients had stertor. Two of seven patients also had a history of reactive airway disease and one with laryngomalacia. Five had a history of reflux. Two of seven patients had weight percentiles at diagnosis lower than the 25th percentile, while the remainder were between 37th and 75th percentiles. Initial voice evaluation revealed stridor in all patients, as well as finding of PVFM on FFL. All patients were started on anti-reflux medication. Average time to resolution of PVFM was 5.9 months after treatment.

CONCLUSIONS

PVFM can be challenging to diagnose in the infant population. PVFM resolves uneventfully with reflux treatment, however, it is unknown whether reflux treatment is essential or if PVFM would spontaneously resolve. The rarity of infantile PVFM mandates formal evaluation and monitoring by a pediatric otolaryngologist.

Working Towards a Common Transatlantic Approach for Evaluation of Exercise-Induced Laryngeal Obstruction

Exertional dyspnea can be a manifestation of dysfunction in a variety of organ systems. Exercise-induced laryngeal obstruction (EILO), a condition previously known as vocal cord dysfunction and paradoxic vocal fold motion, is defined as inappropriate, reversible narrowing of the larynx during vigorous exercise. EILO is usually characterized by typical symptoms, which nevertheless frequently are confused with those of other conditions, including asthma. Laryngoscopy performed as symptoms evolve from rest to peak exercise is pivotal in patient work-up. Moving forward, laryngoscopy findings that definitively characterize EILO need to be defined as do objective measures that can quantitate absolute laryngeal measurements during exercise.

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.

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

Inducible laryngeal obstruction (ILO) is a complex entity and its exact mechanisms are still unclear. It is characterised by transient and reversible narrowing of the larynx in response to external triggers, resulting in symptoms such as cough, dyspnoea and noisy breathing. The prevalence of this condition in adult or paediatric populations is uncertain. Management of ILO starts by establishing an accurate diagnosis, and treatment includes control of trigger factors, breathing and relaxation techniques, and speech and respiratory therapy. The aim of this article is to summarise current understanding and provide a review of the literature of ILO in the paediatric population.

The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction

INTRODUCTION

Exercise-induced laryngeal obstruction (EILO), the condition previously known as paradoxical vocal fold motion and vocal cord dysfunction, is characterized by inappropriate glottic or supraglottic obstruction during high-intensity exercise, causing exertional dyspnea, frequently with stridor. EILO is definitively diagnosed through upper-airway visualization during a characteristic episode. Although respiratory retraining is a primary therapy for EILO, many patients report symptom persistence despite adequate performance of traditional techniques. This report describes three novel breathing techniques for EILO, the Olin EILOBI (EILO biphasic inspiratory) breathing techniques. We include a teaching process and case series with patient-reported assessments.

MATERIALS AND METHODS

Following descriptions of the techniques and teaching process, we present data from a questionnaire offered to all patients who learned at least one of the techniques between September 2015 and March 2017. Subjects evaluated (1) expectation setting, (2) teaching processes, (3) their ability to implement the techniques during high-intensity exercise, and (4) perceived clinical effectiveness.

RESULTS

Ninety-five percent of eligible patients participated, a primarily young, female, and Caucasian sample. Over 50% of subjects competed at the high school varsity level. Sixty-two percent of subjects perceived reasonable expectations, and 82% positively evaluated the teaching process. Seventy-nine percent were able to employ their technique in the high-intensity activity of choice, and 66% perceived clinical effectiveness with the techniques.

CONCLUSIONS

The Olin EILOBI breathing techniques are novel respiratory retraining techniques for use in high-intensity exercise. Case series subjects reported reasonable expectations, a helpful teaching process, the ability to use these techniques during high-intensity exercise, and perceived clinical effectiveness.

Differentiating vocal cord dysfunction from asthma

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

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.

Measuring Quality of Life in Pediatric Paradoxical Vocal Fold Motion Using the SF-36v2

OBJECTIVES

Paradoxical vocal fold motion (PVFM) consists of intermittent adduction of the vocal folds during inspiration, resulting in stridor and worsened by anxiety and stress. The purpose of this study was to assess the impact of PVFM on quality of life in our pediatric patient population.

STUDY DESIGN

This is a prospective, descriptive survey study.

METHODS

Thirty-nine consecutive patients (ages 12-17 years) presenting with a PVFM diagnosis for respiratory retraining sessions with speech-language pathology were recruited. Patients completed a brief demographic questionnaire and the Short Form 36, version 2, a validated tool for measuring health-related quality of life.

RESULTS

There were 31 (79%) girls and 8 (21%) boys with a mean age of 15.5 years. Subjects reported regular participation in competitive extracurricular activities, including track or cross country (30.8%), swimming (17.9%), and cheerleading or dancing (15.4%). Of the patients in the study, 46.2% were straight-A students. On the SF-36 (population averages normalized to a score of 50), the general health of patients with PVFM was better than that of the general population (53.27); however, their physical health limited their role activities more severely (42.82). In addition, a greater proportion of the group with PVFM was at risk for first-stage depression screening when compared with the general population (28% versus 18%).

CONCLUSIONS

We demonstrate a measurable detrimental impact of PVFM on health-related quality of life. This is consistent with previously published literature showing a preponderance of females with PVFM, most of whom are high achievers academically and athletically.

Exercise inducible laryngeal obstruction: diagnostics and management

Obstruction of the central airways is an important cause of exercise-induced inspiratory symptoms (EIIS) in young and otherwise healthy individuals. This is a large, heterogeneous and vastly understudied group of patients. The symptoms are too often confused with those of asthma. Laryngoscopy performed as symptoms evolve during increasing exercise is pivotal, since the larynx plays an important role in symptomatology for the majority. Abnormalities vary between patients, and laryngoscopic findings are important for correct treatment and handling. The simplistic view that all EIIS is due to vocal cord dysfunction [VCD] still hampers science and patient management. Causal mechanisms are poorly understood. Most treatment options are based on weak evidence, but most patients seem to benefit from individualised information and guidance. The place of surgery has not been settled, but supraglottoplasty may cure well-defined severe cases. A systematic clinical approach, more and better research and randomised controlled treatment trials are of utmost importance in this field of respiratory medicine.

The impact of a dedicated physiotherapist clinic for children with dysfunctional breathing

Dysfunctional breathing is a significant cause of morbidity, adversely affecting an individual's quality of life. There is currently no data from paediatric centres on the impact of breathing retraining for dysfunctional breathing. Symptoms and quality of life were measured in 34 subjects referred sequentially for breathing retraining to the first dedicated paediatric dysfunctional breathing clinic in the UK. Data were obtained prior to the first intervention (time point 1), at discharge (time point 2) and by post 6 months later (time point 3). The mean (interquartile range) age of participants was 13.3 (9.1-16.3) years, with 52% female. Data were obtained at time points 2 and 3 in 23 and 13 subjects, respectively. Statistically significant improvements were observed in symptom scores, child quality of life and parental proxy quality of life between time points 1 and 2 (p<0.0001), while there was no significant difference in the data at time point 3 as compared with time point 2. This study suggests that physiotherapist-led breathing retraining offers significant benefit to young people with dysfunctional breathing which is maintained for at least 6 months after treatment is completed. Future studies will provide more information on the long-term effects of interventions for dysfunctional breathing.

Paradoxical Vocal Cord Motion in Pediatric Patients

Paradoxical vocal cord motion (PVCM), also termed vocal cord dysfunction, is a poorly understood disorder of episodic dyspnea characterized by inappropriate vocal cord adduction during inspiration and potentially during expiration. It can coexist or be confused with asthma, so appropriate diagnosis is key to optimizing treatment success. Although many patients with PVCM may have underlying psychologic issues, there is emerging evidence to suggest that this entity is not psychogenic in every patient. Both laryngeal irritants and exercise have been identified as additional contributing factors in PVCM. Diagnosis of PVCM requires awake laryngoscopic confirmation. However, many patients do not exhibit signs of PVCM during this examination, despite provocation during testing. Therefore, clinical history remains key in determining which patients should proceed with behavioral therapy under the guidance of a speech pathologist. In addition, treatment may include limiting patient exposure to potential sources of laryngeal irritation. Refractory patients may benefit from psychologic assessment and treatment. [Pediatr Ann. 2016;45(5):e184-e188.].

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.

Office-based laryngeal injection of botulinum toxin for paradoxical vocal fold motion in a child

We describe the case of a 13-year-old girl with paradoxical vocal fold motion (PVFM) who failed to improve with repeated medical treatment, speech therapy and psychotherapy, but was successfully treated with botulinum toxin A (BTX-A) injection to the vocal folds. For delivering the BTX-A we used a channeled fiber-optic laryngoscope under local anesthesia, in an office setting. The patient remained asymptomatic of PVFM for 5 months, was successfully treated again with the same method, and had no important side effects.

Getting to grips with 'dysfunctional breathing'

Dysfunctional breathing (DB) is common, frequently unrecognised and responsible for a substantial burden of morbidity. Previously lack of clarity in the use of the term and the use of multiple terms to describe the same condition has hampered our understanding. DB can be defined as an alteration in the normal biomechanical patterns of breathing that result in intermittent or chronic symptoms. It can be subdivided into thoracic and extra thoracic forms. Thoracic DB is characterised by breathing patterns involving relatively inefficient, excessive upper chest wall activity with or without accessory muscle activity. This is frequently associated with increased residual volume, frequent sighing and an irregular pattern of respiratory effort. It may be accompanied by true hyperventilation in the minority of subjects. Extra thoracic forms include paradoxical vocal cord dysfunction and the increasingly recognised supra-glottic 'laryngomalacia' commonly seen in young sportsmen and women. While the two forms would appear to be two discreet entities they often share common factors in aetiology and respond to similar interventions. Hence both forms are considered in this review which aims to generate a more coherent approach to understanding, diagnosing and treating these conditions.

Use of botulinum toxin in pediatric otolaryngology and laryngology

The use of botulinum toxin in adult otolaryngology has been commonly used in conditions such as spasmodic dysphonia, cricopharyngeal spasm, palatal myoclonus, sialorrhea, and for cosmetic reasons. The current use of botulinum toxin in pediatric otolaryngology and laryngology has primarily been off label and in children older than 2 years of age. This review discusses the different applications of botulinum toxin in pediatric patients and its effectiveness in treating different pediatric conditions.

Larynx during exercise: the unexplored bottleneck of the airways

Exercise-induced shortness of breath is not uncommon in otherwise healthy young people. Based on the presenting symptoms alone, it is challenging to distinguish exercise-induced asthma (EIA) from exercise-induced obstruction of central airways, sometimes leading to diagnostic errors and inadequate treatment. Central airway obstruction usually presents with exercise-induced inspiratory symptoms (EIIS) during ongoing exercise. EIIS tends to peak towards the end of an exercise session or immediately after its completion, contradicting symptoms of EIA typically peaking 3–15 min after the exercise has stopped. EIIS is usually associated with some form of laryngeal obstruction. Transnasal flexible laryngoscopy performed continuously throughout an incremental exercise test from rest to exhaustion or to intolerable symptoms is usually diagnostic, and also provides information that is important for further handling and treatment. Reflecting the complex anatomy and functional features of the larynx, exercise-induced laryngeal obstruction (EILO) appears to be a heterogeneous condition. Contradicting previous beliefs, recent literature suggests that laryngeal adduction in a majority of cases starts in supraglottic structures and that vocal cord adduction (VCD) most often occurs as a secondary phenomenon. However, EILO is poorly understood and more and better research is needed to unravel causal mechanisms. The evidence base for treatment of EILO is weak. Speech therapy, psychotherapy, biofeedback, muscle training, anticholinergic aerosols have all been applied, as has laser supraglottoplasty. Randomized controlled trials with well-defined and verifiable inclusion and success criteria are required to establish evidence-based treatment schemes.

A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction

BACKGROUND

Vocal cord dysfunction (VCD) or paradoxical vocal-fold motion (PVFM) is a functional disorder of the vocal cords that requires multidisciplinary treatment. Besides relaxation techniques, the use of psychological interventions can help treat the underlying psychological co-morbidities. There is currently no literature that examines the effectiveness of psychological interventions for VCD/PVFM.

OBJECTIVES

To review the evidence for psychological interventions used for the treatment of patients with VCD/PVFM.

DATA SOURCES

We searched electronic databases for English medical literature using Pubmed (Medline), PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Registry of Controlled Trials, and Clinicaltrials.gov. The date range for our search is from June 1964 to June 2014.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies that reported the use of psychological interventions in both adults and children diagnosed with VCD/PVFM. We included randomized controlled trials, case-control studies, retrospective chart reviews, prospective case series, and individual case reports.

RESULTS

Most reported studies are small case series or individual case reports that have described the use of interventions such as psychotherapy, behavioral therapy, use of anti-anxiety and anti-depressant medications, and hypnotherapy in conjunction with breathing exercises taught by speech therapists for symptomatic relief. Among the various psychological interventions that have been reported, there is no data regarding effectiveness and/or superiority of one approach over another in either adult or pediatric patients.

CONCLUSIONS

Psychological interventions have a role to play in the management of adult and pediatric patients with VCD/PVFM. Future prospective studies using uniform approaches for treatment of associated psychopathology may help address this question.

Difficult-to-treat asthma in childhood

Asthma continues to be one of the greatest burdens to healthcare resources throughout the developed world. In most cases, good symptom control can be achieved with low-dose inhaled corticosteroids, and can be cared for in the primary and secondary healthcare systems. However, there is a group in whom control is not achieved despite high-dose inhaled corticosteroids and maximal add-on therapies; these are children with problematic severe asthma that should be referred to a specialist team for further investigation and management. In this review we aimed to provide an evidence-based guide for pediatricians providing care for children with asthma in secondary healthcare settings. The review focuses on a proposed investigation and management strategy for children aged between 6 and 16 years with problematic severe asthma, and is supported as far as possible by evidence from the literature. We first address recent advances in nomenclature and then discuss our proposed course of investigation and management of these children. Distinction of children with true, severe, therapy-resistant asthma from those with asthma that is difficult to treat because of unaddressed underlying modifiable factors is critical and is discussed in detail.

Management of acute severe upper airway obstruction in children

There are many causes of acute severe upper airway obstruction (UAO) in children. The timing of symptom onset and the presence of fever will help to distinguish infectious from non-infectious conditions. Signs and symptoms from congenital malformations often present at birth but may also develop over time. The most common cause of UAO in children is croup. Choking on a foreign body also occurs relatively frequently. Evaluation of the child with UAO starts with a detailed history followed by a thorough physical examination, including an assessment of severity. Severe airway obstruction will result in respiratory failure. This situation requires an immediate response. A child with partial airway obstruction may initially have an adequate airway. However, this situation can deteriorate rapidly. Therefore, providing supportive care and mobilizing resources for definitive airway management may be the most appropriate interventions.