Vocal Cord Dysfunction, Paradoxic Vocal Fold Motion, or Laryngomalacia? Our Understanding Requires an Interdisciplinary Approach
Section snippets
A historical perspective
Periodic occurrence of laryngeal obstruction (POLO) was first described in an 1842 medical textbook by Dunglison,1 who noted a disorder of the laryngeal muscles in hysteric females that he termed, hysteric croup. In the textbook, Principles and Practice of Medicine, Austin Flint2 described a similar syndrome in two male adults and termed the condition, laryngismus stridulus. MacKenzie, however, reported the first evidence of abnormal vocal fold motion visualized by laryngoscopy in 1869. He
Focusing on the big picture
A reasonable first step might be to lump VCD, PVFM, and other similarly presenting disorders into an umbrella classification based on the presence of POLO. Inclusion would be based on unifying chief complaints resulting from episodes of laryngeal obstruction, endoscopic findings, and general commonalities in the characteristics of the clinical presentation. Speculation regarding specific cause would likely bog down the process of classification at this level, and the authors recommend that the
What diagnoses are in the differential?
Any pulmonary disorder that presents with periodic noisy breathing, dyspnea, and secondary complaints, such as cough, could be considered in the differential diagnosis. Asthma has historically been at the top of the list. Chevalier Jackson's axiom is often quoted14: “not all that wheezes is asthma.” Even after his death in 1958, the hunt for asthma masqueraders marches onward. Today, use of the statement that “all that wheezes is not POLO” is avoided; however, VCD, PVFM, and IARP should rank
How do we address cough?
As discussed previously, cough is a complaint in the overall POLO population. Unfortunately, the literature has been inherently limited by a paucity of adequate studies. Lack of agreement on terms and concepts, absence of a structured scientific approach, and small sample sizes have made clinical investigation difficult. The authors' recent literature review (Morris MJ, MD and Christopher KL, MD, unpublished data, 2009), however, can offer insight regarding the overall prevalence of reported
Differences among periodic occurrence of laryngeal obstruction disorders
POLO disorders can be placed into the three separate categories (Table 3). Furthermore, each of the three categories (psychogenic, exertional, and irritant) is composed of several entities. The irritant category is subdivided into extrinsic and intrinsic conditions.
Because most agree that endoscopy is the diagnostic study of choice (Morris MJ, MD and Christopher KL, MD, unpublished data, 2009) for identifying POLO, how do descriptions differ between VCV, PVFM, and IARP? That information may
Endoscopic evaluation
Although characteristic endoscopic findings are discussed, it is difficult to determine relative frequency, as the literature review (Morris MJ, MD and Christopher KL, MD, unpublished data, 2009) demonstrates that endoscopy was not performed in 38% of patients. Inspiratory adduction was reported in 32% of those articles that described endoscopic findings. Descriptions were usually just the acknowledgment of “paradoxical vocal fold movement” or “vocal cord dysfunction” or referred to acronyms.
Paradoxic vocal fold motion
In PVFM, the true vocal folds do not abduct in a normal fashion during inspiration. The true vocal folds paradoxically and symmetrically adduct toward the midline during inspiration,3, 10 producing glottic obstruction. In those individuals with an isolated inspiratory abnormality, the endoscopic characterization is appropriate. PVFM, however, does not adequately describe glottic obstruction that also occurs on exhalation, as the true vocal folds normally adduct to some degree during quiet
Vocal cord dysfunction
The comments made regarding the term PVFM should be underscored and amplified when discussing VCD. Similarly, taken at face value, VCD is the most endoscopically nondescript term in the POLO classification. When looking at the original description of VCD, however, it is defined in the context of a disorder presenting as asthma11 and defines more than one specific endoscopic abnormality. One author of this article (KLC) was the team leader and pulmonologist for the interdisciplinary team in that
Intermittent arytenoid region prolapse
Clinical presentation is discussed later. Endoscopic findings in laryngomalacia in neonates and infants17 include (1) flaccid epiglottis prolapsing backward during inspiration, (2) poorly supported arytenoids that prolapse forward during inspiration, and (3) short aryepiglottic folds.
Collective observations are different in adolescents and young adults and are most commonly seen during strenuous exercise.18 Findings 1 and 3 are generally not present. The following are examples of observations
The three categories of periodic occurrence of laryngeal obstruction
The three categories for POLO (as defined in Table 3) are irritant (intrinsic and extrinsic), exertional, and psychological. Specific underlying conditions in the irritant category are presented in articles elsewhere in this issue. The presence of cough in those disorders also is discussed. Although unconfirmed, the authors suspect that cough is more common in the irritant category than the other two. Other articles in this issue discuss presentation, diagnosis, and management. Speech therapy
Vocal cord dysfunction and mass psychogenic illness
Fourteen adolescent high school girls who developed an audible inspiratory noise and dyspnea were evaluated by an interdisciplinary team and the health department.66 Environmental studies did not demonstrate an environmental noxious chemical or biologic agent. Initially, stridor intensity increased when subjects were in the presence of other affected friends. Stridor was documented on flexible laryngoscopy to be due to the findings of VCD with posterior chink and IARP. The presence of findings
Cough
As discussed previously, cough is encountered in approximately 25% to 42% of POLO disorders in the glottic category. Assessment of the percent frequency of the psychological category relative to purely exertional or irritant categories is speculative due to inadequate data. As discussed in an article elsewhere in this issue, somatization disorder, or perhaps undifferentiated somatoform disorder, is a potential cause of chronic cough but only by exclusion. Because psychological VCD can present
Hypotheses for origin of some laryngeal disorders
Some disorders of the upper airway may be primarily characterized by laryngeal hyperresponsiveness.67 Bucca and colleagues68 evaluated 441 patients with cough, wheeze, or dyspnea without documented asthma or bronchial obstruction. Extrathoracic airway hyperresponsiveness was determined by a 25% fall in maximal midinspiratory flow and was found in 67% of patients. Disease associations included postnasal drip and pharyngitis in 55%, laryngitis in 40%, and sinusitis in 30% of patients.68 The
Flow-volume Relationship
The most common causes of a blunted or truncated inspiratory flow-volume curve are (1) inadequate instruction, (2) suboptimal effort, and (3) inability to perform proper technique.
A reported characteristic finding in VCD, however, is inspiratory FVL truncation consistent with a variable extrathoracic obstruction, as described by Miller and Hyatt.70 In symptomatic patients, this common pulmonary function test can be helpful in suggesting the diagnosis of VCD but does not rule out the diagnosis
Vocal cord dysfunction management
Treatment options for the acute and chronic presentations of VCD are not prospectively well validated and rely primarily on anecdotal reports and collective experience regarding most effective methods. In the authors' review (Morris MJ, MD and Christopher KL, MD, unpublished data, 2009), 665 patients (42% of overall) had various treatment options mentioned; few of these reports or studies prospectively evaluated VCD patients.
Summary
This article presents disorders of POLO resulting in noisy breathing and dyspnea and a variety of secondary symptoms, such as cough. The POLO supraglottic disorder, termed IARP, has historically been called laryngomalacia. PVFM and VCD are POLO glottic disorders. The three categories of POLO of glottic origin are defined as irritant (with intrinsic and extrinsic components), exertional, and psychological. Each of the three glottic disorder categories is composed of several conditions, also
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The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the Department of the Army or the Department of Defense.