Irritant vocal cord dysfunction at first misdiagnosed as reactive airway dysfunction syndrome

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.

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.

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.

Misdiagnosis in occupational and environmental medicine: a scoping review

Introduction

There has been no comprehensive review for misdiagnosis in Occupational and Environmental Medicine (OEM). The possible ramifications of an occupational disease (OD) or an environmental disease (ED) misdiagnosis are not just confined to the individual case but may extend to others exposed to the occupational or environmental hazard. Therefore, a comprehensive scoping review of published literature is imperative for understanding the nature of misdiagnoses in OEM.

Methods

A medical librarian searched MEDLINE (PubMed), EMBASE, and the Cochrane Library (on 06 November 2020). All collected OEM misdiagnoses were classified based on 2 conceptual frameworks, the typical framework, and the causation model. The distribution of misdiagnosis across each medical specialty, each diagnostic step of the typical framework and the causation model, and false-negative and false-positive were summarized.

Results

A total of 79 articles were included in the scoping review. For clinical specialty, pulmonology (30 articles) and dermatology or allergy (13 articles) was most frequent and second-most frequent, respectively. For each disease, occupational and environmental interstitial lung diseases, misdiagnosed as sarcoidosis (8 articles), and other lung diseases (8 articles) were most frequent. For the typical framework, the most vulnerable step was the first step, evidence of a disease (38 articles). For the causation model, the first step, knowledge base, was the most vulnerable step (42 articles). For reported articles, the frequency of false-negative (55 articles) outnumbered the frequency of false-positive (15 articles).

Discussion

In OEM, compared to general medicine, causal misdiagnosis associated with the probability of causation is also important. For making a diagnosis in OEM, a knowledge base about possible ODs and EDs is essential. Because of this reason, the education and training of treating physicians for common ODs and EDs are important. For ODs and EDs, various intentional behaviors of stakeholders should be considered. This scoping review might contribute to the improvement of understanding for misdiagnosis in OEM.

Supplementary Information

The online version contains Supplementary theoretical review and Supplementary materials available at 10.1186/s12995-021-00325-z.

Can Ultrasound Identify Paradoxical Vocal Fold Movement? A Pilot Study

OBJECTIVE

Vocal cord dysfunction (VCD) is characterized by paradoxical vocal fold movement (PVFM) during inspiration. The aim of this study was to determine whether ultrasound could accurately differentiate between normal and PVFM during respirations in a resting state.

DESIGN

Prospective, single-subject design.

SETTING

Academic medical center.

PATIENTS

A speech-language pathologist who was able to volitionally alternate between normal and PVFM when breathing at rest was recruited to participate in the study.

INTERVENTIONS

The subject was instructed to randomly alternate between normal and PVFM 20 times (10 times each). A single investigator imaged the vocal folds using ultrasound and reported when the subject alternated between the 2 respiratory states.

MAIN OUTCOME MEASURES

The subject recorded when they changed between the 2 respiratory states, whether the investigator identified with the change occurred, and if the correct respiratory state was identified.

RESULTS

The investigator recognized when the subject changed respiratory states and correctly identified the new respiratory state 100% of the time.

CONCLUSIONS

The findings of the current study were promising and suggest that ultrasound may have utility in the diagnosis of VCD. However, because of the preliminary nature of these results, further research is required before recommending its clinical implementation.

Laryngeal Dysfunction: Assessment and Management for the Clinician

The larynx is one of the most highly innervated organs in humans and serves a number of vitally important, complex, and highly evolved biological functions. On a day-to-day basis, the larynx functions autonomously, addressing several roles including airway protection, swallowing, and phonation. In some situations the larynx appears to adopt a functional state that could be considered maladaptive or "dysfunctional." This laryngeal dysfunction can underpin and account for a number of respiratory symptoms that otherwise appear incongruous with a clinical disease state and/or contribute to the development of symptoms that appear "refractory" to treatment. These include conditions associated with a heightened tendency for inappropriate laryngeal closure (e.g., inducible laryngeal obstruction), voice disturbance, and chronic cough. Recognition of laryngeal dysfunction is important to deliver targeted treatment and failure to recognize the condition can lead to repeated use of inappropriate treatment. Diagnosis is not straightforward, however, and many patients appear to present with symptoms attributable to laryngeal dysfunction, but in whom the diagnosis has been overlooked in clinical work-up for some time. This review provides an overview of the current state of knowledge in the field of laryngeal dysfunction, with a focus on pragmatic clinical assessment and management.

Vocal cord dysfunction in bronchial asthma. A review article

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

EAACI Position Paper on assessment of cough in the workplace

Cough is a nonspecific and relatively common symptom that can present difficulties in diagnosis and management, particularly when it is reported to be associated with the workplace. The present consensus document, prepared by a taskforce of the Interest Group on Occupational Allergy of the European Academy of Allergy and Clinical Immunology by means of a nonsystematic review of the current literature, is intended to provide a definition and classification of work-related chronic cough (WRCC) to assist the daily practice of physicians facing with this symptom. The review demonstrates that several upper and lower airway work-related diseases may present with chronic cough; hence, the possible link with the workplace should always be considered. Due to the broad spectrum of underlying diseases, a multidisciplinary approach is necessary to achieve a definite diagnosis. Nevertheless, more epidemiological studies are necessary to estimate the real prevalence and risk factors for WRCC, the role of exposure to environmental and occupational sensitizers and irritants in its pathogenesis and the interaction with both upper and lower airways. Finally, the best management option should be evaluated in order to achieve the best outcome without adverse social and financial consequences for the worker.

Paradoxic vocal fold movement disorder

Paradoxical Vocal Fold Movement Disorder (PVFMD) is a cause of dyspnea that can mimic or occur alongside asthma or other pulmonary disease. Treatment with Laryngeal Control Therapy is very effective once the entity is properly diagnosed and contributing comorbidities are managed appropriately. In understanding the etiology of PVFMD, focus has broadened beyond psychiatric factors alone to include the spectrum of laryngeal irritants (laryngopharyngeal reflux, allergic and sinus disease, sicca, and possibly obstructive sleep apnea). The following is a discussion of the history, terminology, epidemiology, diagnosis, comorbid conditions, and treatment of this entity.

Vocal cord dysfunction related to water-damaged buildings

BACKGROUND

Vocal cord dysfunction (VCD) is the intermittent paradoxical adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. Exposure to damp indoor environments is associated with adverse respiratory health outcomes, including asthma, but its role in the development of VCD is not well described.

OBJECTIVE

We describe the spectrum of respiratory illness in occupants of 2 water-damaged office buildings.

METHODS

The National Institute for Occupational Safety and Health conducted a health hazard evaluation that included interviews with managers, a maintenance officer, a remediation specialist who had evaluated the 2 buildings, employees, and consulting physicians. In addition, medical records and reports of building evaluations were reviewed. Diagnostic evaluations for VCD had been conducted at the Asthma and Allergy Center of the Medical College of Wisconsin.

RESULTS

Two cases of VCD were temporally related to occupancy of water-damaged buildings. The patients experienced cough, chest tightness, dyspnea, wheezing, and hoarseness when in the buildings. Spirometry was normal. Methacholine challenge did not show bronchial hyperreactivity but did elicit symptoms of VCD and inspiratory flow-volume loop truncation. Direct laryngoscopy revealed vocal cord adduction during inspiration. Coworkers developed upper and lower respiratory symptoms; their diagnoses included sinusitis and asthma, consistent with recognized effects of exposure to indoor dampness. Building evaluations provided evidence of water damage and mold growth.

CONCLUSION

VCD can occur with exposure to water-damaged buildings and should be considered in exposed patients with asthma-like symptoms.

EAACI consensus statement for investigation of work-related asthma in non-specialized centres

Work-related asthma (WRA) is a relevant problem in several countries, is cause of disability and socioeconomic consequences for both the patient and the society and is probably still underdiagnosed. A correct diagnosis is extremely important to reduce or limit the consequences of the disease. This consensus document was prepared by a EAACI Task Force consisting of an expert panel of allergologists, pneumologists and occupational physicians from different European countries. This document is not intended to address in detail the full diagnostic work-up of WRA, nor to be a formal evidence-based guideline. It is written to provide an operative protocol to allergologists and physicians dealing with asthma useful for identifying the subjects suspected of having WRA to address them to in-depth investigations in a specialized centre. No evidence-based system could be used because of the low grade of evidence of published studies in this area, and instead, 'key messages' or 'suggestions' are provided based on consensus of the expert panel members.

Clinical assessment of occupational asthma and its differential diagnosis

Occupational asthma (OA) is defined as asthma caused by sources and conditions attributable to a particular occupational environment and not to stimuli encountered outside the workplace. Two types of OA are distinguished based on their appearance after a latency period or not. The most frequent type appears after a latency period leading to sensitization; the clinical assessment of this type of OA is the topic of this review. The differential diagnosis of OA is also reviewed, including work-exacerbated asthma, eosinophilic bronchitis, hyperventilation syndrome, vocal cord dysfunction, bronchiolitis, and other causes of dyspnea or cough.

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

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

Chronic cough – occupational considerations

Chronic cough is a common symptom in a wide range of respiratory conditions, and may also occur as a result of upper airway or gastro-esophageal problems. Whilst chronic cough of any cause may be exacerbated by work, in some cases it has a direct occupational cause, resulting from a harmful acute or chronic workplace exposure. Such occupational conditions may only be suspected by taking a detailed occupational history, and directly asking employed patients whether their cough improves away from work. Early and accurate diagnosis, linked with tailored drug therapy, modification of workplace exposures, and expert compensation advice is likely to offer the best outcome for this group of patients.

Vocal cord dysfunction in former World Trade Center (WTC) rescue and recovery workers and volunteers

BACKGROUND

Vocal cord dysfunction (VCD) is a condition characterized by paradoxical partial adduction of the vocal cords on inspiration. It has been associated with exposures to irritants, as well as with psychological illnesses and conditions. Workers who participated in the recovery of the WTC disaster site were exposed to a large amount of irritants as well as considerable psychological stressors. We describe the clinical characteristics of 10 symptomatic former WTC workers diagnosed with this condition, as well as the frequency of spirometric findings suggestive of variable extrathoracic obstruction.

METHODS

Workers who became symptomatic after their WTC work experience have been evaluated clinically by a multidisciplinary team at an academic medical center. The evaluation included history, physical examination, chest radiograph, blood tests, and pre- and post-bronchodilator spirometry in all patients. Additional evaluations and diagnostic tests included otolaryngological evaluation with flexible rhinolaryngoscopy and stroboscopy, gastroenterological and psychiatric evaluations. A randomly selected sample of 172 spirometry results were reviewed for evidence of inspiratory flow limitation.

RESULTS

Variable extrathoracic obstruction was found in 18.6% of the spirometries. Ten patients were diagnosed with VCD. In addition to symptoms suggestive of co-morbid conditions (particularly rhinitis and acid reflux disease), most of the 10 patients had (1) hoarseness, (2) dyspnea that was not associated with bronchial hyperreactivity, or (3) dyspnea associated with asthma, with either mild bronchial hyperreactivity and/or poor response to asthma treatment.

CONCLUSIONS

VCD appears to be part of the spectrum of airway disorders caused by occupational exposures at the WTC disaster site. Further study of this association is warranted.

Paradoxical vocal cord motion disorder: past, present and future

Paradoxical vocal cord motion disorder (PVCM), also called vocal cord dysfunction, is an important differential diagnosis for asthma. The disorder is often misdiagnosed as asthma leading to unnecessary drug use, very high medical utilisation and occasionally tracheal intubation or tracheostomy. Laryngoscopy is the gold standard for diagnosis of PVCM. Speech therapy and psychotherapy are considered the cornerstone of management of this disorder. The aim of this article is to increase the awareness of PVCM among doctors, highlighting the main characteristics that distinguish it from asthma and discuss the recent medical achievements and the possible future perspectives related to this disorder.