Medscape is available in 5 Language Editions – Choose your Edition here.


Vocal Cord Dysfunction

  • Author: Praveen Buddiga, MD; Chief Editor: Michael A Kaliner, MD  more...
Updated: Mar 30, 2016


Vocal cord dysfunction (VCD), also commonly known as paradoxical vocal fold motion, can be characterized as an abnormal adduction of the vocal cords during the respiratory cycle (especially during the inspiratory phase) that produces airflow obstruction at the level of the larynx.[1, 2, 3]

The larynx receives very extensive sensory and motor innervation. With repeated stimulation and excitation by noxious intrinsic and extrinsic irritants, these nerve fibers may become hyperexcitable and hyperresponsive. Consequently, the threshold for activation of the reflex responsible for vocal cords closure is lowered. The underlying pathophysiology of VCD involves a hyperfunctional and inappropriate laryngeal closure reflex.[66, 67]

VCD frequently mimics persistent asthma and is often treated with high-dose inhaled or systemic corticosteroids, bronchodilators, multiple emergency department visits, hospitalizations, and, in some cases, tracheostomies and intubation.[2, 4, 5, 6]

The patients considered here have problems associated with abnormal vocal cord movement without an organic basis. Flow-volume loops obtained during symptomatic periods of wheezing show a limitation of inspiratory flow suggestive of variable extrathoracic obstruction (inspiratory loop flattening). Paradoxical vocal cord motion can be confirmed on laryngoscopy performed when patients are symptomatic.

The clinical history provides limited opportunity to distinguish between patients with VCD and patients with asthma because both groups present with symptoms of wheezing, cough, and dyspnea.[7, 8] The localization of airflow obstruction to the laryngeal area is an important clinical discriminatory feature in patients with VCD.

Another clinical clue may be that patients with VCD often seem to have refractory asthma with poor response to beta-agonists or inhaled corticosteroids.[9, 10] They do not usually report nocturnal awakening due to breathlessness.

Objectively, the data reveal absence of hypoxemia in this subset as compared to compromised persons with asthma.[10]

The hallmark of diagnosis is noted on direct rhinolaryngoscopy; a glottic chink is present along the posterior portion of the vocal cords, while the anterior portion of the vocal cords is adducted.



During the normal respiratory cycle, the vocal cords partially abduct with inhalation and partially adduct with end-exhalation. This phasic vocal cord movement is physiologic, and it allows the unimpeded movement of air inward to the lungs and outward to the atmosphere while maintaining the alveolar patency of the lungs by providing positive airway pressure during expiration (ie, positive end-expiratory pressure [PEEP]).

The larynx, therefore, serves as an upper airway valve to help keep the lungs expanded. For this function, the larynx is richly innervated, and its size is regulated by the activation of striated muscles that are under voluntary and reflexive control. Both laryngeal and respiratory motor neurons influence glottic size, and they, in turn, may be influenced by vagal reflex activity arising from pulmonary and laryngeal receptors.

The mechanisms that cause glottic chink narrowing or intermittent closing during inspiration independent of any changes in lower airway caliber are unknown. In affected patients, the integrated function of the vocal cords ceases episodically, leading to acute intermittent episodes of functional airway obstruction. The clinical signs and symptoms resemble those observed in disorders such as vocal cord paralysis, asthma, epiglottitis, laryngospasm, and angioedema secondary to anaphylaxis.

Recent case reports have described other causes of VCD, such as an inlet patch of heterotopic gastric mucosa in the upper esophagus[11] and exposure to agents such as glutaraldehyde and chlorine inhalation by swimmers or divers.

VCD appears to be part of the spectrum of airway disorders caused by occupational exposures, including irritant exposures and psychological stressors, at the World Trade Center disaster. A recent study evaluating the role of formal psychological testing in patients with paradoxical vocal cord dysfunction found a pattern consistent with conversion disorder in some patients; however, a subset of patients did not appear to be associated with psychopathology.[12]

To summarize, the exact cause of this condition is not clearly evident and may be multifactorial.[10, 13] A hypothesis is that mediation of the vagus nerve may alter the laryngeal tone and lower the threshold for stimuli to produce vocal cord spasm or to precipitate the abnormal adduction of vocal cords. Recent literature suggests a greater emphasis on organic causes such as gastroesophageal reflux and laryngopharyngeal reflux since the laryngopharynx is highly sensitive to gastric acid irritation.




United States

This condition is observed in up to 10% of patients at referral centers seeking evaluation of asthma that is unresponsive to aggressive therapy. The literature reveals a high incidence of VCD in persons with psychiatric conditions (eg, depression, obsessive-compulsive disorder, borderline personality disorder, neuroses induced by childhood sexual abuse),[1, 14] persons with an increased body mass index[6] and medical personnel. VCD may complicate true asthma in a small number of patients.


Mortality rates are unknown, but morbidity is often significant from years of corticosteroid use, resulting in iatrogenic Cushing-like syndrome, bone density loss, and growth suppression in the pediatric population.[10]

Misdiagnosis of VCD as asthma may lead to significant morbidity and increased costs, and misuse of measures of asthma control may be contributing to these findings.[72]


This condition is predominantly observed in females.[12] The authors' review of the published literature indicates a female-to-male ratio of approximately 3:1.


This condition predominates in people aged 20-40 years, but it can occur in people aged 6-83 years. Recent literature suggests an increase of this condition in children and adolescents.

Contributor Information and Disclosures

Praveen Buddiga, MD Physician, Allergy, Asthma and Immunology, Baz Allergy, Asthma and Sinus Center

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

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: MYLAN, TEVA.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael R Simon, MD, MA Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Professor, Department of Internal Medicine, Oakland University William Beaumont 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, Michigan State Medical Society, Michigan Allergy and Asthma Society, American College of Physicians, American Federation for Medical Research, Royal College of Physicians and Surgeons of Canada, Society for Experimental Biology and Medicine

Disclosure: Received ownership interest from Secretory IgA, Inc. for management position; Received ownership interest from siRNAx, Inc. for management position.

Chief Editor

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; 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, Association of American Physicians

Disclosure: Nothing to disclose.

  1. Anbar RD, Hehir DA. Hypnosis as a diagnostic modality for vocal cord dysfunction. Pediatrics. 2000 Dec. 106(6):E81. [Medline].

  2. Bahrainwala AH, Simon MR. Wheezing and vocal cord dysfunction mimicking asthma. Curr Opin Pulm Med. 2001 Jan. 7(1):8-13. [Medline].

  3. Huggins JT, Kaplan A, Martin-Harris B, Sahn SA. Eucalyptus as a specific irritant causing vocal cord dysfunction. Ann Allergy Asthma Immunol. 2004 Sep. 93(3):299-303. [Medline].

  4. Byrd RP Jr, Krishnaswamy G, Roy TM. Difficult-to-manage asthma. How to pinpoint the exacerbating factors. Postgrad Med. 2000 Nov. 108(6):37-40, 45-6, 49-50 passim. [Medline].

  5. Hayes JP, Nolan MT, Brennan N, FitzGerald MX. Three cases of paradoxical vocal cord adduction followed up over a 10- year period. Chest. 1993 Sep. 104(3):678-80. [Medline].

  6. Vlahakis NE, Patel AM, Maragos NE, Beck KC. Diagnosis of vocal cord dysfunction: the utility of spirometry and plethysmography. Chest. 2002 Dec. 122(6):2246-9. [Medline].

  7. Christopher KL, Wood RP 2nd, Eckert RC, et al. Vocal-cord dysfunction presenting as asthma. N Engl J Med. 1983 Jun 30. 308(26):1566-70. [Medline].

  8. Hicks M, Brugman SM, Katial R. Vocal cord dysfunction/paradoxical vocal fold motion. Prim Care. 2008 Mar. 35(1):81-103, vii. [Medline].

  9. Galdi E, Perfetti L, Pagella F, et al. Irritant vocal cord dysfunction at first misdiagnosed as reactive airway dysfunction syndrome. Scand J Work Environ Health. 2005 Jun. 31(3):224-6. [Medline].

  10. Goldman J, Muers M. Vocal cord dysfunction and wheezing. Thorax. 1991 Jun. 46(6):401-4. [Medline].

  11. Silvers WS, Levine JS, Poole JA, et al. Inlet patch of gastric mucosa in upper esophagus causing chronic cough and vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006 Jan. 96(1):112-5. [Medline].

  12. Husein OF, Husein TN, Gardner R, et al. Formal psychological testing in patients with paradoxical vocal fold dysfunction. Laryngoscope. 2008 Apr. 118(4):740-7. [Medline].

  13. Christopher KL, Morris MJ. Vocal cord dysfunction, paradoxic vocal fold motion, or laryngomalacia? Our understanding requires an interdisciplinary approach. Otolaryngol Clin North Am. 2010 Feb. 43(1):43-66, viii. [Medline].

  14. Freedman MR, Rosenberg SJ, Schmaling KB. Childhood sexual abuse in patients with paradoxical vocal cord dysfunction. J Nerv Ment Dis. 1991 May. 179(5):295-8. [Medline].

  15. McFadden ER Jr, Zawadski DK. Vocal cord dysfunction masquerading as exercise-induced asthma. a physiologic cause for "choking" during athletic activities. Am J Respir Crit Care Med. 1996 Mar. 153(3):942-7. [Medline].

  16. Morris MJ, Deal LE, Bean DR, et al. Vocal cord dysfunction in patients with exertional dyspnea. Chest. 1999 Dec. 116(6):1676-82. [Medline].

  17. Wilson JJ, Theis SM, Wilson EM. Evaluation and management of vocal cord dysfunction in the athlete. Curr Sports Med Rep. 2009 Mar-Apr. 8(2):65-70. [Medline].

  18. Al-Alwan A, Kaminsky D. Vocal cord dysfunction in athletes: clinical presentation and review of the literature. Phys Sportsmed. 2012 May. 40(2):22-7. [Medline].

  19. Rundell KW, Weiss P. Exercise-induced bronchoconstriction and vocal cord dysfunction: two sides of the same coin?. Curr Sports Med Rep. 2013 Jan. 12(1):41-6. [Medline].

  20. Allan PF, Abouchahine S, Harvis L, Morris MJ. Progressive vocal cord dysfunction subsequent to a chlorine gas exposure. J Voice. 2006 Jun. 20(2):291-6. [Medline].

  21. Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010 Nov. 138(5):1213-23. [Medline].

  22. Bittleman DB, Smith RJ, Weiler JM. Abnormal movement of the arytenoid region during exercise presenting as exercise-induced asthma in an adolescent athlete. Chest. 1994 Aug. 106(2):615-6. [Medline].

  23. Watson MA, King CS, Holley AB, Greenburg DL, Mikita JA. Clinical and lung-function variables associated with vocal cord dysfunction. Respir Care. 2009 Apr. 54(4):467-73. [Medline].

  24. Balkissoon R, Kenn K. Asthma: vocal cord dysfunction (VCD) and other dysfunctional breathing disorders. Semin Respir Crit Care Med. 2012 Dec. 33(6):595-605. [Medline].

  25. Traister RS, Fajt ML, Landsittel D, Petrov AA. A novel scoring system to distinguish vocal cord dysfunction from asthma. J Allergy Clin Immunol Pract. 2014 Jan-Feb. 2(1):65-9. [Medline].

  26. Chiang WC, Goh A, Ho L, Tang JP, Chay OM. Paradoxical vocal cord dysfunction: when a wheeze is not asthma. Singapore Med J. 2008 Apr. 49(4):e110-2. [Medline].

  27. Newman KB, Mason UG 3rd, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med. 1995 Oct. 152(4 Pt 1):1382-6. [Medline].

  28. Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. 2010 Jan 15. 81(2):156-9. [Medline].

  29. Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006 Jun. 96(6):794-9. [Medline].

  30. Guglani L, Atkinson S, Hosanagar A, Guglani L. A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction. Front Pediatr. 2014. 2:82. [Medline]. [Full Text].

  31. Kass JE, Castriotta RJ. Heliox therapy in acute severe asthma. Chest. 1995 Mar. 107(3):757-60. [Medline].

  32. Manthous CA, Hall JB, Caputo MA, et al. Heliox improves pulsus paradoxus and peak expiratory flow in nonintubated patients with severe asthma. Am J Respir Crit Care Med. 1995 Feb. 151(2 Pt 1):310-4. [Medline].

  33. Grillone GA, Blitzer A, Brin MF, et al. Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A. Laryngoscope. 1994 Jan. 104(1 Pt 1):30-2. [Medline].

  34. Maillard I, Schweizer V, Broccard A, et al. Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement. Chest. 2000 Sep. 118(3):874-7. [Medline].

  35. Dworkin JP, Meleca RJ, Simpson ML, Garfield I. Use of topical lidocaine in the treatment of muscle tension dysphonia. J Voice. 2000 Dec. 14(4):567-74. [Medline].

  36. Wilson JJ, Theis SM, Wilson EM. Evaluation and management of vocal cord dysfunction in the athlete. Curr Sports Med Rep. 2009 Mar-Apr. 8(2):65-70. [Medline].

  37. Parsons JP, Benninger C, Hawley MP, Philips G, Forrest LA, Mastronarde JG. Vocal cord dysfunction: beyond severe asthma. Respir Med. 2010 Apr. 104(4):504-9. [Medline].

  38. Woolnough K, Blakey J, Pargeter N, Mansur A. Acid suppression does not reduce symptoms from vocal cord dysfunction, where gastro-laryngeal reflux is a known trigger. Respirology. 2013 Apr. 18(3):553-4. [Medline].

  39. Bahrainwala AH, Simon MR, Harrison DD, et al. Atypical expiratory flow volume curve in an asthmatic patient with vocal cord dysfunction. Ann Allergy Asthma Immunol. 2001 Apr. 86(4):439-43. [Medline].

  40. Brancatisano T, Collett PW, Engel LA. Respiratory movements of the vocal cords. J Appl Physiol. 1983 May. 54(5):1269-76. [Medline].

  41. Diamond E, Kane C, Dugan G. Presentation and Evaluation of Vocal Cord Dysfunction. Chest. 2000. 118(Suppl 4):199S.

  42. Higgins JC. The 'crashing asthmatic.'. Am Fam Physician. 2003 Mar 1. 67(5):997-1004. [Medline].

  43. Jain S, Bandi V, Zimmerman J, et al. Incidence of Vocal Cord Dysfunction in Patients Presenting to Emergency Room with Acute Asthma Exacerbation. Chest. 1999. 116(Suppl 4):243S.

  44. Landwehr LP, Wood RP 2nd, Blager FB, Milgrom H. Vocal cord dysfunction mimicking exercise-induced bronchospasm in adolescents. Pediatrics. 1996 Nov. 98(5):971-4. [Medline].

  45. Link HW, Stillwell PC, Jensen VK, Laskowski DM. Vocal Cord Dysfunction in the Pediatric Age Group. Chest. 1998. 114(Suppl 4):255S-256S.

  46. Martin R, Blager F, Gay M, et al. Paradoxical vocal cord motion in presumed asthmatics. Semin Respir Med. 1987. 8:332-337.

  47. Maschka DA, Bauman NM, McCray PB Jr, et al. A classification scheme for paradoxical vocal cord motion. Laryngoscope. 1997 Nov. 107(11 Pt 1):1429-35. [Medline].

  48. McFadden ER Jr. Glottic function and dysfunction. J Allergy Clin Immunol. 1987 May. 79(5):707-10. [Medline].

  49. Murray DM, Lawler PG. All that wheezes is not asthma. Paradoxical vocal cord movement presenting as severe acute asthma requiring ventilatory support. Anaesthesia. 1998 Oct. 53(10):1006-11. [Medline].

  50. Newman KB, Dubester SN. Vocal Cord Dysfunction: Masquerader of Asthma. Semin Resp Crit Care Med. 1994. 15:161-167.

  51. O'Connell MA, Sklarew PR, Goodman DL. Spectrum of presentation of paradoxical vocal cord motion in ambulatory patients. Ann Allergy Asthma Immunol. 1995 Apr. 74(4):341-4. [Medline].

  52. O'Hollaren MT. Masqueraders in clinical allergy: laryngeal dysfunction causing dyspnea. Ann Allergy. 1990 Nov. 65(5):351-6. [Medline].

  53. Paparella MM, Shumrick D, Gluckman J, Meyerhoff W. Otolaryngology: Head & Neck. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1991.

  54. Parker JM, Mooney LD, Berg BW. Exercise Tidal Loops in Patients with Vocal Cord Dysfunction. Chest. 1998. 114(Suppl 4):256S.

  55. Patterson DL, O'Connell EJ. Vocal Cord Dysfunction: What have we learned in 150 years?. Insights in Allergy. 1994. 9(6):1-12.

  56. Perkner JJ, Fennelly KP, Balkissoon R, et al. Irritant-associated vocal cord dysfunction. J Occup Environ Med. 1998 Feb. 40(2):136-43. [Medline].

  57. Powell DM, Karanfilov BI, Beechler KB, et al. Paradoxical vocal cord dysfunction in juveniles. Arch Otolaryngol Head Neck Surg. 2000 Jan. 126(1):29-34. [Medline].

  58. Reisner C, Nelson HS. Vocal cord dysfunction with nocturnal awakening. J Allergy Clin Immunol. 1997 Jun. 99(6 Pt 1):843-6. [Medline].

  59. Sandage MJ, Zelazny SK. Paradoxical vocal fold motion in children and adolescents. Lang Speech Hear Serv Sch. 2004 Oct. 35(4):353-62. [Medline].

  60. Schachter AJ. Vocal cord dysfunction may be functional. Chest. 1998 Jul. 114(1):351. [Medline].

  61. Selner JC, Staudenmayer H, Koepke JW, et al. Vocal cord dysfunction: the importance of psychologic factors and provocation challenge testing. J Allergy Clin Immunol. 1987 May. 79(5):726-33. [Medline].

  62. Sokol W. Vocal cord dysfunction presenting as asthma. West J Med. 1993 Jun. 158(6):614-5. [Medline].

  63. Soli CG, Smally AJ. Vocal cord dysfunction: an uncommon cause of stridor. J Emerg Med. 2005 Jan. 28(1):31-3. [Medline].

  64. Weir M, Ehl L. Vocal cord dysfunction mimicking exercise-induced bronchospasm in adolescents. Pediatrics. 1997 Jun. 99(6):923-4. [Medline].

  65. Wood RP 2nd, Milgrom H. Vocal cord dysfunction. J Allergy Clin Immunol. 1996 Sep. 98(3):481-5. [Medline].

  66. Bucca C, Rolla G, Brussino L, De Rose V, Bugiani M. Are asthma-like symptoms due to bronchial or extrathoracic airway dysfunction?. Lancet. 1995 Sep 23. 346 (8978):791-5. [Medline].

  67. Truong A, Truong DT. Vocal Cord Dysfunction: An Updated Review. Otolaryngol. December 08, 2011. S1:002:

  68. CC Maskell, N Pargeter, J Fellows, A Mansur, R Howard. M11 A preliminary biopsychosocial model of Vocal Cord Dysfunction (VCD). Thorax. 2015. 70:A231-A232.

  69. Hicks M, Brugman SM, Katial R. Vocal cord dysfunction/paradoxical vocal fold motion. Prim Care. 2008 Mar. 35 (1):81-103, vii. [Medline].

  70. Morrison M, Rammage L, Emami AJ. The irritable larynx syndrome. J Voice. 1999 Sep. 13 (3):447-55. [Medline].

  71. Dunn N, Katial R, Hoyte F. Vocal cord dysfunction: a review. Asthma Research and Practice. September 22, 2015. 1:9:

  72. Traister RS, Fajt ML, Petrov AA. The morbidity and cost of vocal cord dysfunction misdiagnosed as asthma. Allergy Asthma Proc. 2016 Mar. 37 (2):25-31. [Medline].

Flow volume loops.
Laryngoscopic views of the vocal cords.
Vocal cord dysfunction treatment plan.
Relaxed throat breathing exercises.
Table 1. Differential diagnosis of laryngeal movement disorders [69, 70, 71]
Psychogenic Somatoform disorder, conversion disorder, abuse, anxiety disorder, depression, Munchausen syndrome, malingering
Exercise Exercise
Irritant Extrinsic (chemical irritants, olfactory stimuli)

Intrinsic (GERD, laryngopharyngeal reflux rhinits/post nasal drip, sinusitis)

Laryngospasm Intubation, airway manipulation, IgE mediated, nocturnal aspiration
Vocal Cord Paresis/Paralysis Prolonged intubation, recurrent laryngeal or vagus nerve damage during chest or thyroid surgery, idiopathic
Infectious Epiglottis, bronchiolitis, laryngotracheobronchitis (croup), laryngitis, pharyngeal abscess, diphtheria, pertussis, laryngeal papillomatosis
Neoplastic Head and neck malignancy, cystic hygroma, hemangioma, rhabdomyosarcoma, teratoma, lymphoma, papilloma
Endocrine Thyroid goiter
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.