eMedicine Specialties > Allergy and Immunology > Asthma

Vocal Cord Dysfunction: Differential Diagnoses & Workup

Author: Praveen Buddiga, MD,, Physician, Allergy, Asthma and Immunology, Baz Allergy, Asthma and Sinus Center, Fresno, California
Contributor Information and Disclosures

Updated: Jul 10, 2009

Differential Diagnoses

Anaphylaxis
Asthma

Other Problems to Be Considered

Laryngeal spasm
Foreign body obstruction
Laryngeal abnormalities (eg, neoplasm, polyp, cyst)
Laryngeal edema from C1INH deficiency or ACE inhibitor use

Workup

Laboratory Studies

  • Laboratory studies may be indicated to exclude other diagnoses.
    • Eosinophil count
      • Eosinophilia may suggest the diagnosis of asthma if levels are greater than 5%, but absence of this sign does not clearly exclude the diagnosis, especially if the patient has been frequently treated with oral corticosteroids.
      • Elevated eosinophil counts may also be observed in skin diseases such as atopic dermatitis and in clinical entities such as pulmonary infiltrates with eosinophilia, allergic bronchopulmonary aspergillosis (ABPA), Churg-Strauss syndrome, and parasitic diseases.
      • Vocal cord dysfunction (VCD), itself, is not associated with an elevated blood eosinophil count.
    • Serum immunoglobulin E (IgE) assay
      • Elevated serum IgE is observed in allergic individuals, but it is not specific for asthma.
      • This elevation may be observed in other syndromes such as ABPA and Churg-Strauss syndrome. Its presence may indicate a concomitant diagnosis of asthma even though its absence is not exclusionary.
      • VCD by itself is not associated with an elevated serum IgE level.
    • Arterial blood gases (ABG)
      • ABG findings reveal an alveolar-arterial gradient (ie, the alveolar-arterial oxygen difference), which is a measure of oxygen delivery from the lungs to blood, that is usually within reference ranges in the subset of patients with VCD.
      • In patients with acute asthma, ABG findings may be abnormal, indicative of hypoxemia.
    • C1 inhibitor and C4 levels
      • These levels should be evaluated to exclude hereditary angioedema.
      • This is especially useful if episodes have been prolonged (1-4 d) or if angioedema in other areas or unexplained abdominal pain has occurred in or out of association with episodes of dyspnea.

Imaging Studies

  • Chest radiography
    • Radiographic findings are usually normal, or radiographs may show hyperinflation in asthmatic individuals.
    • Chest radiography may be used to evaluate other pulmonary diseases or structural laryngeal and cardiac abnormalities that may explain or support the patient's respiratory symptoms.

Other Tests

  • Pulmonary function test
    • Spirometric testing supports the diagnosis of VCD in symptomatic individuals.18 This study is used to identify individuals with asthma or other pulmonary abnormalities, including upper airway obstruction. In patients without coexisting asthma, spirometric findings are usually within the reference range during an episode.10 If flows are decreased during an episode, forced vital capacity (FVC) decreases in tandem with forced expiratory volume in the first second (FEV1), which is not consistent with classic airflow limitation.
    • Flow-volume loops are the most useful tool in discriminating between VCD and asthma. Flow-volume loops typically demonstrate inspiratory loop flattening, ie, an inspiratory flow decrease during symptomatic periods suggestive of VCD. In addition, during VCD symptoms, an abrupt drop and rise in the expiratory flow volume loop may be observed in the absence of coughing.

      Flow volume loops.

      Flow volume loops.

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      Flow volume loops.

      Flow volume loops.

    • Results of routine measurement of airflow obstruction (ie, FEV1, peak expiratory flow rate) can be within reference ranges in VCD if the vocal cords close only on inspiration. If vocal cord closure occurs during both inspiration and expiration, FEV1 can decrease along with the decrease in FVC, making the FEV1/FVC ratio within the reference range. This distinguishes isolated VCD from VCD concomitant with asthma, in which the FEV1 is proportionately decreased more than the FVC, representing airflow limitation.
  • Methacholine provocation
    • A patient with VCD shows no bronchial hyperresponsiveness on methacholine challenge unless he or she has concomitant asthma.
    • This challenge is therefore most helpful in excluding the diagnosis of asthma. It may also be helpful in confirming that a patient with VCD has coexisting asthma.
  • Exercise provocation: In a patient in whom exercise or strenuous activity is a primary trigger, a graded exercise challenge on a bicycle ergometer or treadmill is helpful to establish a diagnosis.
  • Allergy skin testing: Perform skin tests to determine the existence of an allergic or environmental trigger or condition (eg, allergic rhinitis, allergic asthma).

Procedures

  • Laryngoscopy
    • The criterion standard for the diagnosis of VCD is direct visualization of the paradoxical adduction of the true vocal cords during inspiration.2,19,18
    • The classic textbook picture is the adduction of the anterior two thirds of the vocal cords with a posterior diamond-shaped chink through which air flows during the inspiratory phase.

      Laryngoscopic views of the vocal cords.

      Laryngoscopic views of the vocal cords.

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      Laryngoscopic views of the vocal cords.

      Laryngoscopic views of the vocal cords.

    • If the patient is not symptomatic at the time of laryngoscopy or rhinoscopy, typical vocal cord changes may often be induced by exercise, hyperventilation, or a maximal forced expiratory effort followed by rapid inspiration.

More on Vocal Cord Dysfunction

Overview: Vocal Cord Dysfunction
Differential Diagnoses & Workup: Vocal Cord Dysfunction
Treatment & Medication: Vocal Cord Dysfunction
Follow-up: Vocal Cord Dysfunction
Multimedia: Vocal Cord Dysfunction
References
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Further Reading

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Keywords

vocal cord dysfunction, VCD, paradoxical vocal cord motion, laryngeal dyskinesia, abnormal adduction of the vocal cords during the respiratory cycle, airflow obstruction, variable extrathoracic obstruction, inspiratory loop flattening, depression, obsessive-compulsive disorder, borderline personality disorder, neuroses induced by childhood sexual abuse, asthma

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Contributor Information and Disclosures

Author

Praveen Buddiga, MD,, Physician, Allergy, Asthma and Immunology, Baz Allergy, Asthma and Sinus Center, Fresno, California
Praveen Buddiga, MD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, and American Medical Association
Disclosure: Glaxo Smith Kline  Honoraria Speaking and teaching

Medical Editor

Stephen Rosenfeld, MD, Professor Emeritus, Department of Medicine, Allergy, Immunology and Rheumatology Unit, University of Rochester School of Medicine and Dentistry
Stephen Rosenfeld, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American Federation for Clinical Research, Clinical Immunology Society, and Medical Society of the State of New York
Disclosure: Elan Ownership interest None; Invitrogen Ownership interest None; Merck Ownership interest None; Pfizer Ownership interest None; Medco Health Ownership interest None; Millipore Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael R Simon, MD, MA, Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Adjunct Staff, Division of Allergy and Immunology, Department of Internal Medicine, William Beaumont Hospital
Michael R Simon, MD, MA is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Federation for Medical Research, Michigan Allergy and Asthma Society, Michigan State Medical Society, Royal College of Physicians and Surgeons of Canada, and Society for Experimental Biology and Medicine
Disclosure: Secretory IgA, Inc. Ownership interest Board membership

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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