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Table of Contents
ORIGINAL ARTICLE
Year : 2015  |  Volume : 17  |  Issue : 2  |  Page : 63-69

Vocal cord dysfunction evaluation and outcome of conservative treatment


1 (On leave) Lecturer of phoniatrics, Department of Otorhinolaryngology, Sohag University, Egypt; Consultant Of Phoniatrics, King Fahd Hospital, Jeddah, KSA
2 Lecturer of phoniatrics, Department of Otorhinolaryngology, El Minia University, Egypt

Date of Web Publication2-Jan-2020

Correspondence Address:
MD (Phoniatrics) Hatem Ezzeldin Hassen
Department of Otorhinolaryngology, King Fahd Hospital P.O. Box: 8488 Jeddah 21196
KSA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274660

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  Abstract 


Objective: This article reports evaluation of 30 patients with Vocal Cord Dysfunction (VCD) and the outcome of conservative management program including voice therapy and breathing exercises.
Study design: A prospective observational follow up study.
Methods: Thirty consecutive referrals of refractory asthma patients and patients presented by laryngeal symptoms diagnosed as having VCD were assessed, treated and followed for at least 6 months after treatments.
Results: 53% of patients had adduction of vocal folds during inspiration, 50% had posterior glottis congestion and 95% had constriction of supraglottic area during inspiration. There was highly significant differences in the scores of both self-reported questionnaire and laryngeal parameters before and after therapy with lowering the scores after voice therapy
Conclusion: There are signs during laryngeal examination which could be used for diagnosis of VCD in between attacks and we can conclude that voice therapy with psychological counseling and anti-reflux treatments are effective in controlling the manifestations of VCD.

Keywords: Vocal cord dysfunction, Paradoxical vocal cord motion, Refractory asthma, Voice therapy


How to cite this article:
Hassen HE, Hasseba AA. Vocal cord dysfunction evaluation and outcome of conservative treatment. Saudi J Otorhinolaryngol Head Neck Surg 2015;17:63-9

How to cite this URL:
Hassen HE, Hasseba AA. Vocal cord dysfunction evaluation and outcome of conservative treatment. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2015 [cited 2021 Apr 21];17:63-9. Available from: https://www.sjohns.org/text.asp?2015/17/2/63/274660




  Introduction Top


Vocal Cord Dysfunction (VCD) is a descriptive term for inappropriate adduction of the vocal folds during respiration. The laryngeal mistiming leads to breathing difficulty and is often misdiagnosed as refractory asthma. Vocal Cord Dysfunction (VCD) and Paradoxical vocal cord movement (PVCM) can be used alternatively to describe the same condition. The etiology of VCD has been unclear. Pulmonary function testing with a flow-volume loop and flexible laryngoscopy are valuable diagnostic tests for confirming VCD. Treatment of VCD includes anti-asthmatics and/or conservative management [1].

Paradoxical vocal fold motion (PVCM) is characterized by paradoxical vocal fold adduction during inspiration, or throughout the respiratory cycle [2]. It results in wheezing, cough, stridor and dyspnea. Although asthma and PVCM can coexist, patients with PVCM are frequently misdiagnosed with refractory asthma. In the emergency department exacerbations may be incorrectly diagnosed as acute asthma or acute upper respiratory tract obstruction resulting in unnecessary tracheal intubation or tracheostomy [3].

The true incidence of VCD in the general population has not been defined, although it is relatively uncommon [4]. In a study conducted by Morris, Allan et al. [5], they reported 1025 patients with dyspnea prescreened and studied, Twenty-nine patients, or 2.8% of all dyspnea patients, were found to have VCD.

VCD has several synonyms, including false croup, Munchausen stridor, psychogenic stridor, hysterical stridor, factitious asthma, emotional laryngeal wheezing, episodic laryngeal dyskinesia or spasm and paradoxical vocal cord motion [6].

VCD may represent a spectrum of diseases with psychological and non-psychological causes neurologic diseases and gastro-esophageal reflux with vocal cord dysfunction represent some of the non-psychological causes. The psychological causes range from simple depression to a subconscious conversion reaction. On numerous occasions there are affected individuals without evidence of any psychopathology. The main trigger factor for VCD associated with psychological causes is emotional stress. Non-psychogenic trigger factors include all common asthma triggers such as dust, cigarette smoke, exercise, occupational irritant exposure, upper respiratory tract infection, laryngopharyngeal reflux (LPR) & misuse and abuse of voice. VCD is most prevalent among young women aged twenty to forty years and is thought to be primarily psychological in causation [7].

Maturo, et al. [8] assumed that the diagnosis is based on case history and the visualization of the abnormal (paradoxical) movement of the vocal folds during flexible laryngoscopic examination and spirometry. This paradoxical movement may be seen following an exercise task such as running, or it may occur spontaneously during restful breathing. Visualization of the vocal folds with flexible fiberoptic laryngoscopy during an acute VCD episode is the current gold standard to confirm the diagnosis.

Patients should be instructed to perform a variety of maneuvers, including phonation, normal breathing, panting, and repetitive deep breaths. The classic finding is inspiratory vocal cord adduction of the anterior two thirds with a posterior diamond shaped “chink.” Inspiratory closure of the vocal cords is sufficient for diagnosis, and not all patients are reported to have the finding of posterior chinking [9].

Previous investigations have reported a high incidence of VCD when the inspiratory portion of the flow-volume loop shows an abnormal inspiratory pattern in asymptomatic or patients previously diagnosed with asthma [4].

The spirometry has been reported as an additional investigation tool in the diagnosis of VCD. Spirometry offers information related to both inspiratory and expiratory events. The flow-volume loop pattern in VCD is characterized by flattening or truncation of the inspiratory limb, compared to a U-shaped pattern in normal subjects [10]. Recently, it has been suggested that the diagnosis of VCD should include both laryngoscopy and pulmonary function testing, though the sensitivity of the flow-volume loop may be low [11].

The cornerstones of therapy for PVFM are voice therapy via voice and breathing techniques and psychological counseling. However, many other treatments have been reported, including heliox, hypnosis, botulinum toxin, sedation, and even intubation and tracheotomy. The efficacy of these treatments, however, has not been systematically evaluated [12].

This aim of this study was to evaluate cases of VCD during and in between attacks and to monitor conservative management including voice therapy and breathing exercises as a treatment modality for VCD.


  Patients and Methods Top


From June, 2011 to December, 2013, patients diagnosed with refractory asthma unresponsive to anti-asthmatic measures at pulmonary department were referred to the phoniatrics clinic. The main symptoms were wheeze, cough and recurrent episodes of stridor. Blood gases analysis revealed normal level of blood gases. Spirometry was done and flow volume loop revealed blunted inspiratory phase in all patients during acute attacks. CT scanning of the thorax demonstrated normal lung fields and normal bronchial airways. These findings increased suspicious of Laryngeal abnormality. The patients were referred to Phoniatrics Unit at El-Minia University Hospital (Tertiary Care hospital) for laryngeal evaluation possible management. Some patients presented directly to the phoniatrics unit and included in the study. All the patients were subjected to the following protocol of intervention.

1. Careful history taking

Thorough history was taken for each patient including history of social stress, psychological problems, sinusitis and LPR.

2. Complete head & neck examination.

3. Endoscopic laryngeal Examination.

All patients initially evaluated by using flexible fibroptic laryngoscopy (Olympus ENF type L3) Also, another evaluation was done after six months after cessation of the voice therapy & breathing exercises. Following a light nasal decongestant, nasal endoscopy (Olympus ENF type L3) was used to examine vocal folds. After insertion and initial acclimatization to the endoscope, The patients examined during quit respiration and different phonation tasks (repeat isolated and sustained vowels, musical glides ah ah repeats, panting, and repetitive deep breaths). The patient then rhythmically tapped his/her feet for 15-30 seconds, and repeated the sequence of breathing quietly through the nose and mouth for ten seconds respectively [13] & [14] .

Rhythmic foot tapping was used to simulate activity without having to remove and re-insert the endoscope. Laryngeal endoscopic recordings for these patients were done and evaluated twice (before starting voice therapy and after 6 months of therapy cessation) by two experienced phoniatricians. The recordings for each patient were evaluated blindly. The two evaluators had neither an idea about the condition of the patient nor an idea about which recording was before or after therapy. Data collected during recording review included epiglottic position, interarytenoid area congestion, adduction of Vocal Folds (VFs) during inspiration, degree of anterior-posterior compression of the supraglottic area, degree of ventricular folds adduction during phonation and respiration. All data were recorded using a visual analogue scale from 0 to 3 as 0= normal, 1=mild, 2= moderate and 3= severe degree. When the two evaluators listed a variable as normal (given score zero) or reported mixed observations for a particular variable, the patient would receive a score of normal for that variable.

4. Self-reported questionnaire

To evaluate the impact of recurrent attacks of respiratory difficulties on the patients activity, life style and their perception to this condition, The patients were invited to answer a self-reported questionnaire. The questionnaire reported by Maat et al; [7] was validated by double translation by 3 bilingual speech language pathologists (Arabic and English languages speakers). This questionnaire included sixteen items and divided into two subscales, Psychosocial impact of the condition and Physical impact of stridor (items of the questionnaire are presented at the appendix). The alpha Cronbach’s reliability of the questionnaire was 0.82. Each item was scored on a 4-point scale where’s zero = no effect & three = severe effect, it was distributed to the patient to fill it twice (one before starting voice therapy and the other six months post therapy program.

5. Conservative treatment program

Long term: Treatment of predisposing factors as cough, asthma & allergy. Avoidance of pollutants and respiratory irritants. Avoid triggers as smoke and air borne irritants. Treatment of LPR and rhinosinusitis (when present) and psychological counseling. Short term: The patient was constantly assured that he had been evaluated and that his condition had been diagnosed accurately and it could be treated successfully with voice rehabilitation, that included relaxation techniques.

  • During acute attack, Quick Sniff Technique was use., The patient was asked to sniff (open VFs) then blow with prolong exhalation with pursed lips on “ssssss”, “shhhhhh”, “ffffffff”, “whhhhhhhh”.
  • In between attacks, voice therapy sessions by Smith accent method of voice therapy [21] were done to the patients, each for 20 minutes twice per week for 3 months. The first formal therapy session addressed self-awareness about what happens during an episode of stridor, the use of diaphragmatic breathing for relaxation and generalized muscle tension reduction. The session began with the patient a clear and simple explanation of how the respiratory system coordinates with the phonatory system and how they are affected by muscular tension. Simplified color charts and diagrams of the upper airway downloaded from the internet were used to complement the verbal explanations. The patient was taught how to execute diaphragmatic breathing while concentrating on lip seal, the tongue lying flat on the floor of mouth and the muscles of the face and jaw maintaining a relaxed state. Therapy sessions focused on increasing the patient’s self-awareness of his breathing patterns, increasing his rate respiration using the relaxation techniques established in earlier sessions, without the interference of unnecessary muscular tension.
  • The patient was then advised to begin gentle and low-impact exercises such as walking while using relaxed breathing techniques. This was done to encourage the patient to return to a lifestyle that was as normal as possible, giving consideration to his respiratory requirements. He was advised that should he have an episodic attack, he should stop, sit down to regain his composure and breath slowly to encourage relaxation of the laryngeal musculature. [13] & [14].


Statistical analysis

Wilcoxon signed rank test was used for comparison between results before and after treatments. Spearman Rho correlation was conducted between continuous variable and Chi Square test was used in categorical variables. The calculations were performed with the statistical program SPSS 22. P values < 0.05 were considered significant. A formal consent of approval was taken from each patient to be included in this study.


  Results Top


Thirty patients were included in this study (16 male and 14 females). The age range of the studied group ranged from 16 years to 40 years (M=25& SD = 6.7). Demographic data of the subjects and different symptoms are presented at [Table 1].
Table 1: Demographic findings and the symptoms

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Most of the patients (80%) were suffering from stridor and wheezy chest during acute attacks as reported at pulmonary department. Four cases presented to our phoniatric clinic during acute attacks and they are managed successfully according to the previous protocol of management. 53% of cases were males, 17 % had sinusitis, 20% had nasal allergic history and 30% had social stress as anxiety, depression and panic attack. History suggestive of laryngopharyngeal reflux represented 20% of the cases. 10 patients reported abuse/misuse of their voices and 15 patients reported prolonged bouts of cough at the onset of the complaint. Spirometry was performed for all patients and revealed flattening of inspiratory loop [Figure 1].
Figure 1: Spirometry: flattening of the inspiratory loop

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There were different laryngeal findings in between the attacks of PVFM as demonstrated in [Table 2].
Table 2: Laryngeal findings, number, percent &the mean score

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Fifty three per cent of cases had varying degrees of adduction of vocal folds during inspiration with triangular posterior chink [Figure 2], 50% had post. displacement of epiglottis [Figure 3],, 50% had interarytenoid congestion, and 95% had compression of laryngeal inlet and adduction of ventricular folds with inspiration [Figure 4] &[Figure 5].
Figure 2: Posterior chick during inspiration loop

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Figure 3 :Posterior displacement of epiglottis

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Figure 4: Ant-Post Compression

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Figure 5: Ventricular hyper-adduction

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Regarding the efficacy of conservative treatment for the management of patients diagnosed as having PVFM, Wilcoxon signed Rank test was used to compare the scores of laryngeal evaluation parameters before and after therapy and also to compare the results of the self-reported questionnaire before and after voice therapy as presented in [Table 3] & [Table 4].
Table 3: The mean scores and standard deviation of different laryngeal parameters (before and after therapy)

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Table 4: The mean scores (total, and the two sub-scales) of the questionnaire before and after speech therapy.

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According to [Table 3], there were highly significant differences between the mean scores of the evaluated laryngeal parameters before and after conservative therapy according to Wilcoxon Signed Rank test. The mean scores post therapy in all parameters were lower than the mean scores pre-therapy (lowering the scores mean less severity of the condition).

[Table 4] demonstrates lowering the mean scores of total as well as the two sub-scales of the questionnaire post therapy. Wilcoxon Signed Rank test revealed a highly significant difference between the scores pre and post treatments (P-value <0.05).


  Discussion Top


Our series of patients with VCD comprised adults males (53%) and adult females (47%). Our findings of a male sex predominance are inconsistent with previous demographic findings that VCD affects adolescent girls [15]. This result could be explained by that adolescent males may be more active and performing more exercise and physical activity and they might be exposed more to dust and irritants. Most of the patients carried a diagnosis of refractory asthma. Asthma and VCD can occur simultaneously but the lack of response to asthma medication, a change in asthma pattern and the presence of inspiratory obstruction of spirometry testing should increase the suspicion of VCD [16] .

In between attacks the measurements of blood gasses were normal (oxygen saturation about 98 %) for almost all the patients. This picture might explain that the condition is episodic and the patient had no complaint in between attacks.

Most of the patients complained of stridor and wheezy chest during the attacks and these symptoms are in agreement with other research work carried out by Maturo et al; [8] & Kothe et al; [17]. in which the most common complaint among their patients were dyspnea and stridor.

In the current study, The patients experienced multiple predisposing and triggering factors as allergy, smoking, LPR and social stress, and these factors are considered precipitating factors to the occurrence of the attacks. Altman et al. [15] concluded in their study that social stresses, LPR and allergy are considered factors predispose to the occurrence of PVCM.

In the current study, 4 cases were in active attacks of stridor, once diagnosis of VCD was settled, assurance of the patient and training by quick sniff and prolonged slow expiration technique were done. This method could alleviate respiratory obstruction and save the patient from unneeded tracheostomy. The majority of our patient had mild laryngeal manifestations in between attacks during evaluation using fiberoptic naso-endoscopy.

The laryngeal irritability and jerky movements of laryngeal structures may be explained by hyper-excitability of the larynx due to either allergy, LPR or other environmental irritants. Hoy et al. [18] proposed that occupational exposures may initiate and/or trigger recurrent hyperkinetic laryngeal symptoms, predominantly episodic dyspnea, dysphonia, cough and sensation of tension in the throat.

In the current study, the main manifestations were supraglottic constriction and approximation of ventricular folds during inspiration. Interaytenoid congestion was observed mildly in 45% of patients and only 20% of the patients presented by positive history of LPR. Atypical laryngeal configurations were observed including abnormality of the anterior-posterior dimension and ventricular fold hyper-adduction. This could be explained by unawareness of the manifestations of LPR and mild nature of this problem at our patients. All these results support the hypothesis that VCD is episodic and not continuum and exists as a manifestation of laryngeal instability.

However, these results are inconsistent with the results of Treole et al. [19] who studied fifty patients with paradoxical vocal fold movements by endoscopy in between the attacks, they observed paradoxical adduction of the vocal folds during the respiratory cycle in all of participants with PVFD, although they were asymptomatic. This may be explained by false interpretation of irritability and jerky movements of the larynx in between attacks ( described by the authors) as PVCM.

In the current study voice therapy with Psychological counseling and management of LPR in affected patients were considered effective management as these procedures lowered the manifestations and all the patients were satisfied by the results as indicated by the significant differences between the scores of the questionnaire and the scores of laryngeal evaluations before and after six months of treatments.

Voice therapy trains the patient in diaphragmatic breathing that diverts the conscious attention away from the larynx and also helps focus on expiration as compared with inspiration [3]. Our results of the efficacy of this program of treatment were consistent with previous results done by Murry et al; & Wilson [12],[20].

The limitations of this study are the small size of subjects and absence of more longitudinal follow up for the patients.


  Conclusion and Recommendations Top


Vocal cord dysfunction could be suspected in asthmatic patients refractory to medications mainly adolescent ages. The combination of spirometry and naso-endoscopy as an assessment tools are essential in diagnosis. There are laryngeal manifestations in between the attacks that may help to shift our attention to this diagnosis mainly antero-posterior constriction during inspiration and more approximation of ventricular folds with inspiration. Conservative treatment including voice therapy & breathing exercises interventions focusing on respiratory control of VCD in adolescent patients in combination with psychological counseling and management of LPR are effective treatments resulting in control the symptoms for six months. Further research is needed to compare efficacy of voice therapy alone versus voice therapy, psychological therapy and anti-reflux measurements. Further research is also necessary to determine if VCD is harbinger of more serious psychiatric illness.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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